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Psychological
Disorders

Eating Disorders

Psychological
Disorders

Addiction
Anxiety Disorders
Eating Disorders
Depression and Manic Depression

Keel Foreword by Pat Levitt. Ph.D. Vanderbilt Kennedy Center for Research on Human Development Vanderbilt University .Psychological Disorders Eating Disorders Pamela K.

Please call our Special Sales Department in New York at (212) 967-8800 or (800) 322-8755. Title. — (Psychological disorders) Includes bibliographical references and index.E18K44 2005b 616. Pamela K. 1970– Eating disorders / Pamela K. . p. some addresses and links may have changed since publication and may no longer be valid. No part of this book may be reproduced or utilized in any form or by any means. cm. For information contact: Chelsea House An imprint of Infobase Publishing 132 West 31st Street New York NY 10001 ISBN-10: 0-7910-8540-6 ISBN-13: 978-0-7910-8540-0 Library of Congress Cataloging-in-Publication Data Keel.Eating Disorders Copyright © 2006 by Infobase Publishing All rights reserved. institutions. without permission in writing from the publisher. Eating disorders I. II. Psychological disorders (Chelsea House Publishers) RC552. or by any information storage or retrieval systems.com Text and cover design by Keith Trego Printed in the United States of America Bang EJB 10 9 8 7 6 5 4 3 2 This book is printed on acid-free paper.. ISBN 0-7910-8540-6 1. Because of the dynamic nature of the web. You can find Chelsea House on the World Wide Web at http://www. including photocopying. Keel. or sales promotions. associations.chelseahouse. electronic or mechanical. All links and web addresses were checked and verified to be correct at the time of publication. recording.85'26—dc22 2005021406 Chelsea House books are available at special discounts when purchased in bulk quantities for businesses.

Table of Contents Foreword 1 Introduction 2 Anorexia Nervosa 3 Bulimia Nervosa 4 Binge Eating Disorder and Eating Disorders Not Otherwise Specified 5 Causes of Eating Disorders 6 Treatment 7 Future Directions vi 1 10 29 48 58 74 84 Notes 94 Glossary 97 Further Reading 102 Websites 103 Index 105 .

Ph. By design. like changes that occur in disorders such as drug addiction. Genes and the environment are powerful forces in building the brain during development. are organized into a type of architecture that is far more complex than any of today’s supercomputers. the way we learn new information involves changes in circuits that actually improve performance. For example. but its connections are capable of changing to improve the way a circuit functions. Yet some change can also result in a disruption of connections. not only is the brain’s connective architecture more complex than any computer. schizophrenia. the human brain is made up of billions of cells called neurons. which use chemical neurotransmitters to communicate with each other through connections called synapses. Each brain cell has about 2000 synapses. anxiety or attention disorders. and even how susceptible we are to such diseases as depression. which can severely vi .Foreword Pat Levitt.D. but can also be the root causes of psychological and neurological disorders when things go awry. depression. or even changes that can increase a person’s risk of suicide. and then multiply that by infinity! Even the most enthusiastic of mathematicians and physicists acknowledge that the brain is by far the most challenging entity to understand. epilepsy. and ensuring normal brain functioning. The way in which brain architecture is built before birth and in childhood will determine how well the brain functions when we are adults. And. Connections between neurons are not formed in a random fashion. but rather. Kennedy Center for Research on Human Development Vanderbilt University Think of the most complicated aspect of our universe.

during development. like controlling body physiology—our patterns of sleep. with almost all the vii . In a sense. such as seeing. viral infection or fetal exposure to alcohol can increase the risk of developing a wide range of psychological disorders later in life. how we can improve its functioning. are neuroscientists. Genes are very important in controlling the initial phases of building the brain. Even small abnormalities that occur during early brain development through gene mutations. Those who study the relationship between brain architecture and function. and how well we recall old information. our ability to learn and store new information. feeling. and the diseases that affect this bond. almost every gene in the human genome is needed to build the brain. fears and emotions. or even our eating habits. for example. In fact. understanding how the brain is built can lead us to a clearer picture of the ways in which our brain works. and more. and what we can do to repair it when diseases strike. Over the last 50 years. Those who study and treat the disorders that are caused by changes in brain architecture and chemistry are psychiatrists and psychologists. much like a hard-wired computer. the circuits that control these functions. then. The brain does all this.FOREWORD disturb brain function. The brain controls our feelings. hearing. This process of brain development actually starts prior to birth. Brain architecture reflects the highly specialized jobs that are performed by human beings. Each specialized area must communicate well with other areas for the brain to accomplish even more complex tasks. smelling and moving. both of which can become disrupted if brain development or function is disturbed in some way. by building. Different brain areas are specialized to control specific functions. we have learned quite a lot about how brain architecture and chemistry work and how genetics contribute to brain structure and function.

the highly detailed connectivity that emerges during childhood depends greatly upon experiences and our environment. like physical abuse. and ceilings. we are using experience to model our brain connections to function at . In building a house. The brain is assembled similarly. But the work is not yet complete. While there are thousands of chemical building blocks. A young child who experiences toxic stress. But for all of this early work. we use specific blueprints to assemble the basic structures. begins by this time. floors. to put the architecture together. Experience is powerful. that are used. even during sleep. in fact. like the basic circuitry of the brain. will have their brain architecture changed in regions that will result in poorer control of emotions and feelings as an adult. extending through puberty. which is termed ‘experience-dependent’ development. The assembly of the architecture.viii FOREWORD neurons we will ever have in our brain produced by mid-gestation. When we repeatedly practice on the piano. are put in place early in the building process. During the first three years of life. such as proteins. or shoot a basketball hundreds of times daily. and by birth. in the form of intricate circuits. much like bricks and mortar. walls. there is another very important phase of development. The brain of a child is being built and modified on a daily basis. Plumbing and electricity. like a foundation. our brains actually form far more connections than we will ever need. Experience is not just important for the circuits that control our senses. we have the basic organization laid out. because billions of connections form over a remarkably long period of time. the early circuits form in this way so that we can use experience to mold our brain architecture to best suit the functions that we are likely to need for the rest of our lives. almost forty percent more! Why would this occur? Well. lipids and carbohydrates.

in the old adage ‘use it or lose it. We also know that. the architecture can break down. physical exercise can be quite powerful in helping to reorganize circuits so that they function better. Your brain chemistry and ix .FOREWORD their finest. just like the architecture of houses may differ in terms of their functionality. Some will achieve better results than others. healthy brain to learn or repair itself following an accident. For example. perhaps because the initial phases of circuit-building provided a better base. The aging process can be particularly hard on the ability of brain circuits to function at their best. perhaps we can use those same tools to optimize the functioning of aging brains. We are working to understand the brain structure and function that results from the powerful combination of genes building the initial architecture and a child’s experience adding the all-important detailed touches. If we understand the mechanisms that make it easy for a young. you just feel better. even in an elderly individual. The difficulties in understanding how architecture gets built are paralleled by the complexities of what happens to that architecture as we grow older. Synapses may be lost and brain chemistry can change over time. Dementia associated with brain deterioration as a complication of Alzheimer’s disease or memory loss associated with aging or alcoholism are active avenues of research in the neuroscience community. We already know many ways in which we can improve the functioning of the aging or injured brain. There is truth. for both development and in aging. And you know that when you exercise and sleep regularly. like an old home. because positive change comes less readily as we get older.’ Neuroscientists are pursuing the idea that brain architecture and chemistry can be modified well beyond childhood. for an individual who has suffered a stroke that has caused structural damage to brain architecture.

why we smile when thinking about the Thanksgiving turkey.x FOREWORD architecture are functioning at their best. can actually damage brain chemistry and change brain architecture so that it functions more poorly. Pat Levitt. the way we perceive the world. you are a neuroscientist. too. These same types of drugs.D. the images of altered brain organization and chemistry will come to mind in thinking about complex diseases such as schizophrenia or drug addiction. how we recognize color. Tennessee . Ph. Another example of ways we can improve nervous system function are the drugs that are used to treat mental illnesses. But also keep in mind that as neuroscientists. and the world in which we leave live. Vanderbilt Kennedy Center for Research on Human Development Vanderbilt University Nashville. These drugs are designed to change brain chemistry so that the neurotransmitters used for communication between brain cells can function more normally. As you read the series Psychological Disorders. we are on a mission to comprehend human nature. If you are interested in people. or how we can remember the winner of the 1953 World Series. the emotion of experiencing our first kiss. when taken in excess or abused. Director. however. There is nothing more fascinating and important to understand for the well-being of humans.

As they continued to search for the cause of her weight loss. but her parents insisted that there must be something physically wrong with their daughter. Desperate for a clue about what was going on. After two weeks of this. She had started losing weight about two months before her 12th birthday. Milaena’s diary provided a daily log of 1 . At first.5 kg) and was 4 feet. Milaena described her terror that she would be the fattest girl at her birthday party and detailed her plan to lose weight. her parents took her to the doctor. Her parents did not know what to do to help their daughter. her parents blamed her loss of appetite on the flu that had been going around. She weighed 78 pounds (35. They felt certain that she wasn’t eating because she was sick. 11inches (1. However. In the diary. The doctor asked whether Milaena might have an eating disorder. all along saying that she just wasn’t hungry. Milaena’s mother read Milaena’s diary.7 kg) over the course of nine weeks.Introduction 1 Milaena was brought into treatment for an eating disorder shortly after her 12th birthday. Milaena continued to lose weight. An extensive physical exam and tests showed no cause for Milaena’s weight loss. looking back to when the problem first began. Milaena continued to complain that she wasn’t hungry at meals even after she felt well enough to go to school.5 meters) tall. losing 17 pounds (7.

2 Eating Disorders Figure 1.1 A preoccupation with one’s weight is a result of eating disorders. and binge eating jeopardize their health to maintain or achieve a weight that is less than average for their particular height. . People with disorders such as anorexia nervosa. bulimia nervosa.

Introduction

the exact number of calories she was eating, the exact number of calories she was burning, and the estimated number of
calories she was getting rid of by vomiting intentionally. Her
parents took her for medical treatment immediately after
reading the diary, but they feared that they had already lost
their daughter. They felt that they could no longer trust her,
and they worried that Milaena would never forgive them for
invading her privacy.

Like thousands of girls, Milaena suffers from an eating disorder. Eating disorders include problems with eating too little and
problems with eating too much. Although eating disorders
often involve weight problems (weighing too little as a result of
not eating or weighing too much because of overeating), many
people who suffer from eating disorders do not look particularly underweight or overweight. In addition, not all people who
are underweight or overweight have an eating disorder. Almost
everyone overeats at one time or another, and most girls have
gone on a diet, eating far less than would be considered normal
or healthy. Overeating and dieting are not, in themselves, eating
disorders. However, they may be related to the risk for developing an eating disorder (Figure 1.1).
ANOREXIA NERVOSA

Anorexia nervosa is a condition in which a person starves him-

or herself. The key feature of this eating disorder is the refusal
to eat enough food, resulting in a body weight that is far
below a healthy level. Sometimes, individuals with anorexia
nervosa are described as looking “painfully thin.” This is a
good description because many people with anorexia nervosa
experience a lot of physical discomfort because of their low
body weight. In addition to having a low weight, people with

3

4

Eating Disorders

St. Catherine of Siena
Understanding the history
of eating disorders is difficult because few historical
texts deal with the emotional experiences of girls or
women. One exception to
this is St. Catherine of
Siena (1347–1380). Born
into a wealthy home before
becoming
a
Roman
Catholic nun, Catherine was
a prolific writer who left
behind many accounts of
her own experiences with
fasting.
Catherine’s difficulties
with eating first appeared
during her childhood. As a child, she refused to eat meat, would
engage in religious fasts, and had a fierce independent streak.
After her older sister died in childbirth, Catherine developed a
deep antipathy toward marriage and motherhood. She cut off
her hair and took measures to make herself unattractive.
At about age 16, Catherine developed a pattern of self-starvation. She started by consuming only bread, water, and vegetables. At around 23, she eliminated bread and vegetables and
lived on communion wafers, water, and bitter herbs. She would
suck and chew on bitter herbs and spit out the juice and saliva. In addition to extreme fasting, Catherine engaged in strenuous physical activities, including cleaning, service to the poor,

Introduction

and long, vigorous walks. Catherine also engaged in selfinduced vomiting.
Catherine viewed her self-starvation as a form of illness that
she was forced to bear, in her own words (translated from the
original) Catherine wrote, “I prayed continually and I pray to
God and will pray that he will grace me in this matter of eating
so that I may live like other creatures.” Despite her prayers, it
is clear that Catherine’s behaviors were intentional. Church
superiors were concerned that Catherine’s extreme fasting
would result in death by her own hand—or suicide, which is a
sin within the Catholic Church. According to writer Rudolph
Bell, in response to these concerns, “Catherine shot back that
eating would kill her anyway so she might as well die of starvation, and do as she wished in the meantime.” Catherine
died from the effects of starvation on April 29, 1380, at the
age of 33.
Whether Catherine suffered from anorexia nervosa has long
been debated. It is certain that a fear of becoming fat did not
motivate her food refusal. Thus, she does not meet the diagnostic criteria for anorexia nervosa. Cases of “spiritual starvation”
have been found in women in the 20th century in the United
States. These cases resemble anorexia nervosa in all respects
with one exception: They do not appear to be motivated by a
desire to lose weight. Perhaps in modern-day patients, fear of
becoming fat is an interpretation of self-starvation rather than
its cause. A challenge in understanding any eating disorder is
distinguishing between the causes and effects of the disorder.
Sources: Bell, Rudolph M. Holy Anorexia. Chicago: University of Chicago Press,
1985; Bynum, Caroline W. Holy Feast and Holy Fast: The Religious Significance
of Food to Medieval Women. Berkeley: University of California Press, 1987.

5

the disorder is not a “modern” condition. These individuals may believe they are fat even when they are extremely thin. British physician Sir William Gull first used the term anorexia nervosa to describe several adolescent female patients who engaged in self-starvation that led to severe weight loss.0% of all females.2 Cases of anorexia nervosa have been described . or they may feel that controlling their weight is more important than anything else. Anorexia nervosa has become more common over the last 100 years.1 described l’anorexie hysterique. Just prior to Gull’s description of the disorder. and saints of the Roman Catholic Church from the 1200s to 1700s who all appear to have suffered from self-starvation conditions. they may deny the dangers associated with their low weight.000 men) at some point in their lives. In 1874. however.5% to 1. a persistent pattern of self-starvation among adolescent girls. In the experience of both physicians.05% to 0. a French physician.000 to 1 in 1. There is also evidence that anorexia nervosa exists in many different cultures.2 Historical documents describe fasting girls in the 1800s. Anorexia nervosa is far less common in males. In girls and women.6 Eating Disorders anorexia nervosa have an intense fear of gaining weight or becoming fat. That means that between 1 in 200 and 1 in 100 females suffer from anorexia nervosa at some point in their lives. Anorexia nervosa occurs most often in adolescent and young adult women and has been estimated to affect 0. Examining historical texts suggests that anorexia nervosa may have existed long before it was officially recognized at the end of the 1800s. some patients recovered after refeeding. Charles Lasegue.1% of men (or 1 in 2. anorexia nervosa also involves the loss of menstrual periods. while others died from starvation despite intense efforts on the part of relatives and doctors to help them. miraculous maids in the 1700s. affecting 0.

05% to 0. affecting 0. Estimates suggest that 0. BULIMIA NERVOSA Bulimia nervosa is characterized by episodes of binge eating in which an individual feels a loss of control over food consumption and eats very large amounts of food in single sittings.3 In addition to being a modern problem. British physician Gerald Russell first used the term bulimia nervosa in 1979 to describe normal-weight female patients who binged and vomited. bulimia nervosa appears to be a problem restricted to Western cultures such as the United 7 . laxative abuse. Bulimia nervosa appears to be a modern problem. or excessive exercise. bulimia nervosa is far less common in males.3% of men (or 1 in 2. like anorexia nervosa. Bulimia nervosa most often occurs in adolescent and young adult females.Introduction in patients who have had no prior exposure to Western ideals of beauty. The person then uses extreme measures to avoid weight gain. with the disorder affecting as many as 1 in 5 college women. such as self-induced vomiting. which suggested a link between the two eating disorders.5% to 3. fasting. Many of these patients had suffered from anorexia nervosa prior to developing bulimia nervosa.0% of women (1 in 200 to 1 in 33) at some point in their lives. However.000 to 1 in 300) suffer from bulimia nervosa at some point in their lives. Like people with anorexia nervosa. Rates of bulimia nervosa increased dramatically over a very short period of time in the second half of the 20th century. individuals with bulimia nervosa base their self-worth on their weight and shape. diuretic abuse. Recent data suggest that rates of bulimia nervosa may have peaked in the 1980s. such as an 18-year-old nomadic girl from the Middle East who had lived her entire life in the desert with no exposure to modern media. Bulimia nervosa is more common than anorexia nervosa.

However. for every three women with binge eating disorder. Historical references to gluttony suggest that problems with overeating are not new. individuals with binge eating disorder tend to be significantly overweight. The disorder affects approximately 30% of people (1 in 3) who are trying to lose weight through a weight control program.7% to 4% of the general population (1 in 100 to 1 in 25 people). Binge eating disorder is considered an eating disorder not otherwise specified (EDNOS) because individuals with the disorder have a clinically significant problem controlling their eating but they do not fulfill the requirements to be diagnosed with either anorexia nervosa or bulimia nervosa. a person does not have to be overweight to be diagnosed with binge eating disorder. there are two men with binge eating disorder. the difference between women and men is smaller than for anorexia or bulimia nervosa. Of the various EDNOS.8 Eating Disorders States and England or to individuals who have been exposed to Western ideals. As a result of frequent binge eating episodes. Specifically. the most research has been completed on binge eating disorder. It is more common among women than men. BINGE EATING DISORDER AND OTHER EATING DISORDERS NOT OTHERWISE SPECIFIED (EDNOS) Binge eating disorder (BED) is characterized by binge eating in the absence of extreme weight control behaviors. It is not possible to determine whether rates of binge eating disorder have risen or fallen over time. or obese. the disorder is . however. Binge eating disorder affects 0. People who have other EDNOS include those who purge after eating normal amounts of food. individuals who chew food and then spit it out. However. and people who do not meet the full criteria for a diagnosis of either anorexia nervosa or bulimia nervosa.

there is no evidence that eating disorders are less common in women of other ethnic/racial minority groups.4 Binge eating disorder is also more common in white women than African-American women. Differences among groups in risk for developing eating disorders provide important leads for understanding the causes of eating disorders (see Chapter 5). Specifically. This assumption has been supported for some eating disorders in some comparisons of ethnic/racial groups. Moreover. anorexia nervosa and bulimia nervosa appear to be less common in African-American women than in white women. Instead. This association has led some individuals to assume that mainstream ideals would only place members of racial/ethnic majority groups at risk. It does not seem that white girls are at a particularly increased risk for developing eating disorders. but the difference in frequency was less dramatic. EATING DISORDERS AND RACE/ETHNICITY Eating disorders have been closely tied to cultural ideals of feminine beauty. 9 . adolescents from many ethnic/racial backgrounds have similar rates of disordered eating attitudes and behaviors. Aside from lower rates of eating disorders in African-American women. it seems that African-American girls may be protected from developing anorexia nervosa and bulimia nervosa.Introduction of little concern in times and cultures where food is too scarce to allow for binge eating episodes.

First.2 Anorexia Nervosa I have heard girls and women say that they wish they could have anorexia. then it must not be easy for individuals with anorexia nervosa to lose weight. individuals with anorexia nervosa are able to lose a lot of weight. So. the idea of having anorexia nervosa is appealing to some people because it seems to be a way to lose weight easily. “at least for a little while. Strangely. Not only is it impossible for both of these things to be true. Most individuals who fail to lose weight or fail to maintain weight loss feel they have failed because of some personal weakness. but it turns out that both are false. If it really were easy for people with anorexia nervosa to lose weight. if it takes great willpower to resist urges to eat. these two views are contradictory. it is clear that most individuals find it very difficult to lose weight.” This wish seems to come from two aspects of anorexia nervosa that are appealing. people who have anorexia nervosa seem to have incredible willpower. People who have anorexia nervosa never seem to fall prey to the same weaknesses of appetite. Second. Having anorexia may be viewed as a means to a makeover. Given the increasing rates of overweight individuals and obesity and the multibillion-dollar diet industry. then they would not be demonstrating great willpower. There is nothing easy about what individuals with anorexia nervosa go through in their pursuit of 10 . However.

At then end of the 8th grade. and her boyfriend. Each year of high school. with her perfect 4. She was also a star student. This. had been chosen top male student. when she should have been voted homecoming queen.0 grade point average. combined with her annual title of homecoming princess.Anorexia Nervosa weight loss. Ashley was elected to the homecoming court until her senior year. In addition. the person’s intense fear of food and eating is not. other stories came out as 11 . It chooses them. but Ashley had remained in the lead throughout high school. placed Ashley at the top. Ashley had been part of a popular and competitive group of female friends who had been together since junior high. Each girl in the group wanted to become valedictorian for the graduating class. People with anorexia nervosa may choose not to eat. Most members of her clique were straight-A students and active in extracurricular activities. when she was caught cheating on an exam in precalculus. She had always been an athlete and played on all the team sports through junior high and high school. People who say that they wish they could have anorexia nervosa might as well wish that they could contract a deadly parasite that would eat away at their bodies. but had also always been very aware of who was doing the best. They had always been supportive of each other. Todd. but they do not choose to have anorexia nervosa. After her cheating was revealed. although the refusal to eat is intentional. she had been voted top female student in front of the school assembly. Individuals with great willpower are those who fight against anorexia nervosa despite the intense fear and feelings of loss of control it causes. Ashley’s problems began during the spring of her junior year. CASE STUDY Ashley developed anorexia nervosa during her senior year of high school.

She was placed on academic probation. they were told she was too busy to talk on the phone. Ashley followed each diet religiously. Ashley started to watch what she was eating and began to work out on her own. the boys started to confront her directly. She started to buy magazines that promised physical perfection. When fall nominations for homecoming queen were . Ashley did not know how to respond. By the end of her junior year. Ashley’s cheating resulted in a failing grade in precalculus. she became fascinated by the increasing muscle definition she achieved with her new workout. To make up for lost practices. but had taken credit for their work.12 Eating Disorders well. Each article offered different explanations of how the body used food for energy and different advice on how to use diet and exercise to achieve the perfect body. Ashley had just a small list of foods that she would eat. Her new workout regimen helped fill the time she used to spend at practice and hanging out with her friends. Other girls said that if they called Ashley to find out what they had missed at school after a sick day. Even those girls who felt sorry for Ashley were worried about their own reputations in school and were careful to express their support only in private and to express their disapproval in public. She found that exercising and weight loss gave her a sense of order and control that she was lacking since losing her academic reputation and her circle of friends. adding the requirements of one diet to the rules she was already following from previous diets. Some girls said Ashley had not been helpful on group projects. While the girls whispered behind Ashley’s back. and was suspended from the softball team. making suggestive jokes at her expense. Although Ashley had never been fat. Soon. Several of Ashley’s friends felt that Ashley had betrayed them. Without her group of friends to support her. was expelled from the honor society.

Ashley’s parents did not know what to think about Sarah’s concerns. Ashley felt that she needed to be better than Sarah at something. At the same time. 7 inches (1. Ashley misunderstood Sarah’s dismay when Ashley could fit into Sarah’s clothes. Ashley thought that Sarah felt inferior. She talked with some of her closest friends to get advice. Sarah wasn’t sure what to do. Ashley denied the accusations and felt more alone than ever. Sarah was horrified to see Ashley’s rib cage when she was changing clothes. Ashley chose weight. Sarah believed that Ashley would have received As even without cheating and thought that Ashley’s cheating was related to her fears of failure. this made the situation worse. Sarah became concerned about Ashley’s weight loss. Rumors started circulating around school that Ashley had an eating disorder.5 meters). At 5 feet. Ashley was more than 8 inches (20 cm) taller than Sarah. she had always weighed less than Ashley. however. 11 inches (1. Ashley stopped talking to Sarah and blamed Sarah for all her problems. as judgment against her for having an eating disorder. Ashley was grateful for Sarah’s friendship. her best friend from junior high school and one of her former friends. who was not quite 4 feet. Ashley was confronted by the far-reaching effects of her fall from grace—she was not nominated. Because Sarah was so short. Sarah was one of the few who would still talk to Ashley. All of the criticism that had been leveled at Ashley after her cheating came back in a new form. Ashley decided that she would change that. Of Ashley’s friends. However. Sarah decided to talk to Ashley’s parents about Ashley’s eating habits and weight loss. Sarah knew that Ashley did all of the assigned reading and homework and studied many hours for every exam. Instead. Sarah. Instead. became homecoming queen.7 meters) tall. Sarah was short and round and a bundle of energy. but agreed to take 13 .Anorexia Nervosa announced.

competitive. 6 inches (1. She deliberately maintains a weight that is well below normal for her height. thinks. she had not menstruated for over seven months. However. Ashley challenged the accuracy of the measurements because she knew that she was 5 feet. too. Ashley’s case demonstrates many of the symptoms and features of anorexia nervosa. the doctor shared her medical findings with Ashley’s parents. and . Ashley insisted that eating so much food would make her fat. She expresses an intense fear of becoming fat and does not recognize the dangers of maintaining her current low weight. Ashley is perfectionistic (although not actually perfect).67 meters). She could not tolerate the idea of being fat. Ashley was horrified by the amount of food she was being asked to eat.5 kg). and her weight was measured at 93. When the doctor explained the number of calories adolescent girls should eat to stay healthy. However. Because Ashley was not yet 18 years old. similar to what is often seen in elderly people. making her weight 72% of what would be expected for her height. she had not been concerned when her periods stopped altogether. Because her periods had always been irregular during sports seasons. and is motivated by an intense fear of failure. She has also stopped her menstrual cycles. Like many patients with anorexia nervosa. Ashley had also stopped menstruating.5 pounds (42. Ashley’s height was measured at 5 feet.14 Eating Disorders Ashley to a doctor who could discuss healthy ways to manage her weight. 7 inches. She was already unpopular at school. the doctor explained that Ashley’s extreme dieting may have caused some bone loss and shrinking. EFFECTS OF ANOREXIA NERVOSA Anorexia nervosa affects how a person feels.

bone. and behaviors actually occur because of what anorexia nervosa does to the body.1). but also muscle. However. The loss of such vital components causes the body to age prematurely. anorexia nervosa involves significant weight loss. behaves. When the body lacks food to use for fuel. and bone (Figure 2. and it also affects physical health and how the individual gets along with other people. “shrinking” as an elderly person’s frame might and increasing the risk for bone fractures. thoughts. organ tissue.1 Anorexia nervosa results in a loss not only of body fat. Many of the condition’s effects on feelings. it switches to other bodily tissues when it is starving. The lack of food also prevents the body from building new tissue. Although the body uses fat tissue first. Most individuals think of weight loss as a loss of fat. but also muscle. it begins to break down body tissue for energy.Anorexia Nervosa 15 Figure 2. Physical Effects of Anorexia Nervosa By definition. which can lead to significant delays in growth during adolescence . weight loss in people with anorexia nervosa is due to a loss of not only fat. and even organ tissue.

anorexia nervosa has the highest risk of death. and blood pressure. bowel function. and hair loss. low blood pressure. In addition to the loss of menstrual function Ashley showed. sleeping properly. Without enough food. some people with anorexia nervosa develop a fine. lanugo appears to serve the same purpose. The gray matter is where brain cells (neurons) are located.16 Eating Disorders as well as major delays in healing after an injury. They also constantly feel cold because their bodies cannot control their temperature. Ashley’s height was reduced because of bone loss. slow heart rate. Patients with anorexia nervosa have increased ventricle size and decreased brain mass. patients with anorexia nervosa have problems with regulating body temperature. Finally. In addition to losing weight. The brain contains gray matter and white matter with a core of ventricles that contain cerebrospinal fluid in the center. heart rate. Approximately 1 in 20 patients die. Lanugo is a kind of hair that develops as the fetus grows in the womb to help regulate the fetus’s body temperature. This is both a result of general restlessness and a lack of fat to cushion bones from surfaces. Compared to other mental disorders. The loss of organ tissue includes the loss of brain tissue. anorexia nervosa can lead to death. constipation. downy hair all over their body called lanugo. In patients with anorexia nervosa. many systems of the body cannot function normally. Although anorexia nervosa causes hair loss in most patients. People with anorexia nervosa suffer from insomnia. Loss of bone mass increases the risk of serious bone fractures. . and they often have a difficult time finding a comfortable position. These neurons enable the brain to receive information about the outside environment and about what is happening inside the body and to send information to the muscles about how to react to these cues.

Planning is the ability to decide 17 . planning. Decision-making is the ability to decide whether to continue reading this chapter. Some patients reach a point at which they literally want to weigh nothing at all—they want to lose weight until they don’t exist anymore. The desire to live and thrive decreases so much that nonsuicidal patients with anorexia nervosa are similar to suicidal patients in that they are more repelled by life and less repelled by death. suicide is a leading cause of death in anorexia nervosa. For Ashley. decisionmaking. compared to nonsuicidal psychiatric patients and healthy people. this emotional numbing may have helped her cope with the losses she experienced after she was caught cheating. recall. or stop reading altogether. The person sees further weight loss as a way to relieve the overwhelming fear. Cognitive abilities include attention. Attention is the ability to keep your mind focused on this sentence. Although they may feel less sad and angry. They stop crying. Cognitive Effects of Anorexia Nervosa The word cognitive refers to thoughts and thought processes. and problem-solving. All of their emotions are reserved for one specific thing—fear of losing control over eating and weight. Recall is the ability to tell someone else what cognitive means without looking it up. Memory is the ability to remember what this sentence said as you read the next sentence. people with anorexia nervosa also feel less happy and engaged. memory.5 In addition to starvation. They stop laughing. People with anorexia nervosa believe that if they can just lose more weight.Anorexia Nervosa Emotional Effects of Anorexia Nervosa For many individuals with anorexia nervosa. increased weight loss only makes the anxiety and fear worse. grab a different book. they will no longer feel frightened. Instead. Anxiety becomes increasingly intense and paralyzing. weight loss is accompanied by emotional numbing.

Subjects in the study were conscientious objectors to World War II. such as planning to read one chapter of a book each day so that you will finish it by the end of a week. conducted a study to understand the effects of starvation and the best ways to restore weight. the research subjects were placed on a . Although conscientious objectors could not be asked to serve their country in ways that would lead to another person’s death. they could be drafted to take part in research that would help rehabilitate World War II soldiers. After completing medical and psychological evaluations to confirm their health. and the ability to solve prob- Minnesota Starvation Study In the 1940s. shorter chapters in a single day so you can finish the book in one week. a researcher at the University of Minnesota. In addition. such as when you realize that there are eight chapters in your book and only seven days in the week and decide to read two. conscientious objectors were ideal subjects because they did not differ physically or psychologically from the men who went to war.18 Eating Disorders on a course of action that will lead to some desired future outcome. Problem-solving is the ability to resolve conflicts. people with anorexia nervosa have problems with attention. memory. The purpose of the study was to understand how to help World War II soldiers who had been held prisoner in Nazi concentration camps. Given the effects of anorexia nervosa on brain tissue. Ancel Keys. Specifically. it is not surprising that the disorder impairs the ability to think. concentration. Men who had been disqualified for military service for physical or psychological reasons might not respond to starvation or refeeding the way that soldiers would.

Anorexia Nervosa

lems. Intelligence test scores have been shown to decrease during the illness and return to pre-illness levels after the weight
returns to a healthy level. Although individuals who undertake
fasts claim to experience increased clarity of thought and may
seem very rational and unemotional, individuals with anorexia
nervosa often make irrational statements and draw irrational
conclusions. For example, Ashley is unable to understand that
her dramatic weight loss upsets Sarah because Sarah is worried
about Ashley’s health. Instead, she expects that Sarah would feel
envious of Ashley’s figure. People with anorexia nervosa may
claim that they follow a healthy diet that reduces the risks of

diet to produce extreme
weight loss. This study provided valuable information
about the effects of starvation. During the course of
weight loss, the men in the
study became withdrawn
and depressed. Although
none of these men sought
weight loss for personal
reasons, the conscientious
objectors showed many of
the same food obsessions
seen in patients with Conscientious objectors to World
War II were subjects in a study to
anorexia nervosa. In fact, understand the effect of starvation.
after successfully returning
to their normal weight, several of the study’s participants went
into food-related careers, such as becoming chefs.

19

20

Eating Disorders

obesity. In fact, they are ignoring the health risks associated with
their starvation, which may be even more dangerous than being
overweight. They ignore evidence that they were less obsessed
with their eating and weight before they developed anorexia
nervosa. They claim that their fears will be resolved if they carefully follow a specific regimen and reach a specific target weight.
People who have anorexia nervosa may claim that the physical
discomfort they feel while eating poses a more serious threat to
their health than not eating.
Anorexia nervosa is often accompanied by preoccupations
with food, eating, and weight. For example, Ashley spends a
great deal of time poring over magazine articles about diets and
exercise. Some of this behavior may be explained by the effort
required for the patient to maintain a diet strict enough to cause
significant weight loss or to maintain a very low weight.
However, a famous study conducted in the 1940s in Minnesota
suggests that much of this is a consequence of starvation rather
than its cause (see “Minnesota Starvation Study, pages 18–19).
Behavioral Effects of Anorexia Nervosa

In addition to preoccupations with food, eating, and weight, people who suffer from anorexia nervosa develop rituals. These rituals may include keeping detailed records of the calories they consume and burn, and how much they weigh. In addition, individuals may engage in elaborate rituals at mealtimes. These serve to
increase the amount of contact they have with food while limiting the amount of food they actually eat. Common rituals include
eating foods that are normally eaten with utensils with the fingers, cutting food into very small pieces, putting strange combinations of foods together, adding unusual seasonings and condiments to foods (for example, adding mustard to oatmeal), or
eating food from a single small dish. Individuals may also engage
in specific rituals for weighing themselves, weigh themselves

Anorexia Nervosa

repeatedly throughout the day, or check specific body parts (for
example, they may check to see if they can wrap their fingers
around their wrist or count a specific number of ribs).
Exercise regimens can also become highly ritualized. A person may intend to do 45 sit-ups. If he or she gets interrupted at
number 43, the person will start over again from the beginning,
in order to complete exactly 45 sit-ups.
The preoccupations and rituals seen in people with anorexia
nervosa resemble the behaviors of people who have obsessivecompulsive disorder. This anxiety disorder leads sufferers to do
things like repeatedly wash their hands or turn light switches on
and off a specific number of times before leaving a room.
Interestingly, anorexia nervosa and obsessive-compulsive disorder frequently occur at the same time in the same individual.
Interpersonal Effects of Anorexia Nervosa

Individuals with anorexia nervosa often become increasingly
socially isolated. Their refusal to eat cuts off participation in
many social activities, and they may even avoid attending events
if food will be present. Avoiding these events may be motivated
by a fear that they will lose control and eat, or by a fear of having people notice that they do not eat. The effects of starvation
may make it difficult for individuals with anorexia nervosa to
follow normal, everyday conversations. In addition, the effects
of starvation on emotions may reduce a person’s motivation to
interact with others.
A person with anorexia nervosa may choose to engage in
extensive exercise regimens instead of spending time with
friends and family. In Ashley’s case, her social isolation appeared
to serve as a trigger for her anorexia nervosa. In addition, her
peers’ reactions to her problems isolated her further. However,
the decision to focus all of her attention and energy on eating
was made by Ashley. For Ashley, this was her way to avoid

21

there are individuals who weigh considerably less than what is considered average for their height. There is a wide range of body types that are normal and healthy for different people. it often does (Figure 2. This process can be especially distressing for adolescent boys who feel that they are too skinny and not as muscular as they would like to be. Being underweight may be a normal part of adolescent development for many people.2). For people who have daily interactions with a person who is suffering from anorexia nervosa. Thus. why did it take so long for anyone to notice? Although it seems hard to believe that a condition that is so physically obvious would go unnoticed. or developed new friendships. the person’s weight on one may not be markedly different from his or her weight on the next. and gender. age. These people often have thin parents and thin relatives. but they do not have a problem. and weight eventually catches up to height. Even people who are not thin in their natural constitution may go through a period in adolescence when their height shoots up but their weight does not keep up.22 Eating Disorders directly dealing with the effects her cheating had on her friendships and reputation in school. focused on the few friendships that survived the incident. Ashley might have tried to repair her friendships. These periods of uneven growth are usually time-limited. Losing significant amounts of weight does not happen overnight. They are simply naturally thin. people may gradually get used to seeing the . As a result. RECOGNIZING ANOREXIA NERVOSA Why didn’t Ashley’s parents see that their daughter was in trouble before Sarah approached them? Why didn’t Ashley’s teachers notice that something was wrong? If Ashley was so emaciated from starvation. Being underweight is not the same thing as having anorexia nervosa. Rather than pursuing the perfect body.

23 . anorexia nervosa. most specifically. Dramatic weight changes may be noticed only when looking at pictures taken several months earlier or by someone who has not seen the person for a longer period of time (such as a grandparent or other extended family member). Indeed. there is a tendency to applaud weight loss rather than worry about it.Anorexia Nervosa Figure 2.2 This table shows some of the demographics on eating disorders. Most people view weight loss as a positive change. many individuals who develop anorexia nervosa at first receive praise for losing weight and for seeming to demonstrate willpower around food. person weigh less without noticing the weight loss. Because many people are overweight and actively diet to try to lose weight.

That means the clothes that he or she wore before should still fit (although they might be a little too short after the growth spurt). he or she will not have actually lost any weight. Thus. Sometimes. So. the person may wear baggy clothes to keep others from noticing that he or she has lost an alarming amount of weight. At other times. Sometimes they wear large. A second sign would be cessation of growth and developmental processes. People with anorexia nervosa often wear clothes that hide their weight and shape. of course. Regardless of the actual motivation that underlies wearing oversized clothes. it might be worth trying to figure out whether the person is wearing clothes that once fit or clothes that were bought larger than he or she needs. if a person seems to be swimming in his or her regular clothes. baggy clothes because they feel that they weigh too much and are embarrassed by the size of certain body parts. it may be difficult for others to notice significant weight loss. because it is not possible to see the person’s body clearly.24 Eating Disorders Current ideals of beauty in Western societies like the United States are significantly underweight. an individual with anorexia nervosa may also fail to grow in height during adolescence. is weight loss. an individual whose . Although individuals who are constitutionally thin or are going through a growth spurt during adolescence may appear to be very thin. how does one tell if a person may be suffering from anorexia nervosa? The first sign. Given that low weight may be normal for some individuals and may be hidden from view. people with anorexia nervosa wear large clothes because they feel cold and need several layers of clothing to keep warm because of the effects starvation has on the body’s ability to regulate temperature. In addition to loss of menstrual cycles in females. Portraying extremely thin actresses and models as beauty icons makes it harder for people to recognize that these states are unhealthy.

people should not sacrifice important academic and social activities or sleep in favor of self-imposed exercise plans. A third sign would be if the person displays odd behaviors around food. ineffective dieting is the norm. such comments may be an attempt to make heavier girls feel inferior. although self-deprecating comments are normal among teenage girls. time-consuming exercise workouts that seem to go beyond what would be required for health or athletic performance. Again. Although dieting is extremely common among teenage girls. A fifth sign would be extensive. and exercise. many girls are on diets that they do not stick to very well. since exercising under these conditions could cause serious health problems. A fourth sign would be if a very thin person makes self-deprecating comments that suggest that he or she believes him. If they are sincere. then it is reasonable to conclude that he or she may have anorexia nervosa. Such behaviors may be masked by claims that the person is too busy to eat or has already eaten. If a person does not need to lose weight and yet seems to be very dedicated to avoiding specific foods or eating very small portions. 25 . If a person is never seen eating and is underweight.Anorexia Nervosa development seems to have halted or even reversed may be showing the effects of self-starvation. Similarly. such comments may represent significant disturbances in the way the person perceives his or her body. If they are insincere. for girls who are underweight. comments about being fat are simply inappropriate. as is the case with anorexia nervosa.or herself to be overweight. this may be a sign of anorexia nervosa. then he or she may have anorexia nervosa. if an underweight person engages in strange rituals around eating that prolong the amount of time required to eat and reduce the actual amount of food eaten. That is. eating. Similarly. People should be willing not to exercise when they are sick or injured.

remember that suspicion is not the same as fact. there may be other reasons for weight loss. and may withdraw from friends. Pretending that nothing is wrong may seem like silent approval to a person who has an eating disorder. use an information-seeking approach. Do not assume that you already know what is happening. food refusal. Doing nothing is unacceptable. regardless of the underlying reason. . a person who is undergoing chemotherapy for cancer may experience hair and weight loss. Even if the person seems to show all the signs of anorexia nervosa. may be unable to eat certain foods due to nausea. and talking to friends provides reassurance. Talking to your friends to get their opinion on whether or not someone has an eating disorder is also not a good idea. since the physical effects of significant weight loss are the same. The person who may have an eating disorder may feel like you are gossiping and trying to hurt him or her by discussing private problems with others. and social withdrawal. Although it is highly unlikely that the person would be engaging in strenuous exercise. because doing nothing may reduce anxiety and avoid conflict. So. Eating disorders are dangerous conditions that can ultimately lead to death. what should you do if you suspect that someone you know may have an eating disorder? First.26 Eating Disorders HOW TO RESPOND TO SUSPICIONS OF AN EATING DISORDER This section will start with what you should not do in response to suspicions that a person has an eating disorder. his or her condition may well mimic much of what was described for anorexia nervosa. Unfortunately. Your friends won’t know any more than you do whether or not someone has an eating disorder. Both responses are probably the most common responses to suspicions. both responses make the person who suspects there is a problem feel better without necessarily offering any benefit for the person who may have an eating disorder. To find out what’s going on. For example.

In contrast. instead. it is better to talk to a school counselor or nurse than to a teacher. efforts to help stop the eating disorder may feel like an attempt to change the person. Both school counselors and school nurses have received education and training to allow them to help students with mental health concerns like eating disorders. the first criterion for anorexia nervosa is a refusal to maintain a minimum healthy weight. Thus. peer counselors undergo a great deal of training and receive supervision before they help others. For example. For these reasons. will be able to try to help the student in question. Seek out information on eating disorders and be willing to listen in a way that will be supportive of the person but not of the eating disorder. Indeed. or a rejection of who and what the person is. This sounds much easier than it is. a school guidance counselor will maintain the confidentiality of what you discuss. Although peer counseling can be helpful. Because an individual with anorexia nervosa views 27 . and believes in. and can help reduce your concerns. talk to someone who is in a position to help the person about whom you are concerned. to be diagnosed with anorexia nervosa. Ego-syntonic means that the disorder does not feel like something that is happening to them. Because anorexia nervosa is ego-syntonic. cares about.Anorexia Nervosa Second. a person must demonstrate deliberate attempts to reduce weight or to maintain a very low weight. the person about whom you are concerned may feel betrayed if you speak with someone he or she has as a teacher. Do not attempt to be the person’s therapist. this makes it seem like part of the person. As a result. If you have concerns about the ability of school counselors to respond to this issue. For most individuals with anorexia nervosa. a teacher does not necessarily have this kind of background. It feels like something that they want to do. In addition. it feels like something they are choosing to do. you may wish to speak with a school nurse. their disorder is ego-syntonic.

However. Parasites are capable of changing the behavior of the host to allow the parasite to survive. Anorexia nervosa promotes a series of behaviors that increase the strength of the eating disorder at the expense of the person. It is important to remember that the person existed as a unique individual before anorexia nervosa developed. Anorexia nervosa.28 Eating Disorders him. Anorexia nervosa does not exist without the person it afflicts. . too. it’s important to remember that this is an illusion created by the illness. Parasites are biological organisms that cannot exist without a host. they never chose to develop anorexia nervosa. Although people with anorexia nervosa choose not to eat. • • • • • • • SUMMARY A useful way to think about anorexia nervosa when supporting a friend or relative is to view anorexia nervosa as a parasite. Finally. often by depleting resources intended to further the host’s survival. parasites can kill their hosts. feeds off of its host.or herself as merged with the disorder. Parasites thrive by feeding off of the host. it becomes hard for others to see the person differently. Anorexia nervosa can kill that person if not treated. even at the expense of the host’s survival. if not treated and removed.

Death is over 10 29 . Although people with bulimia nervosa and people with anorexia nervosa may display very similar behaviors—binge eating and purging— those who have bulimia nervosa do not reach a weight that is much lower than what would be expected for their age and height. This is because many people who suffer from anorexia nervosa also have bulimic symptoms. most people who have anorexia nervosa and do not recover eventually develop binge eating and/or purging behaviors. In fact. Most importantly. Maintaining a relatively normal weight appears to protect individuals with bulimia nervosa from many of the negative consequences described in Chapter 2 for people with anorexia nervosa. When followed over time. there is a far lower risk of death with bulimia nervosa than with anorexia nervosa. which involves the use of fasting and exercise to produce and sustain weight loss). These individuals are considered to have the binge-purge subtype of anorexia nervosa (as opposed to the restricting subtype. the relative frequency of bulimic symptom patterns (bingeing and vomiting).Bulimia Nervosa 3 Bulimia nervosa is far more common than anorexia nervosa in the United States. then what exactly distinguishes bulimia nervosa from anorexia nervosa? The simple answer is weight. far outstrips the frequency of the purely restricting eating patterns. If many individuals with anorexia nervosa also binge and purge.

and the potential for these risks to contribute to death over a prolonged period of time is not known. Their eating problems appear to be one more expression of underlying difficulties in coping with emotional stress. those who have bulimia nervosa are viewed as having little self-control. interpersonal problems. . participation in extracurricular activities. in an overall comparison. generalizations about people with bulimia nervosa are neither logical nor accurate. Bulimic symptoms tend to be highly ego-dystonic.30 Eating Disorders times more likely for a patient with anorexia nervosa than one with bulimia nervosa. Many individuals with bulimia nervosa are reasonably high functioning in terms of grades in school. individuals with bulimia nervosa are more likely to view themselves as suffering from their eating disorder. Bulimia nervosa still has medical risks. they are often perceived as being secretive and deceitful. it would seem that health is less severely compromised in bulimia nervosa than in anorexia nervosa. Does the lower death rate mean that bulimia nervosa is a less severe disorder? Not necessarily. Unlike with anorexia nervosa. and there is little admiration for individuals who suffer from binge/purge patterns. That is. the behaviors would have to be a hidden problem in a person who seemed to be functioning reasonably well in other aspects of life. I have never heard people say that they wish they had bulimia nervosa. In addition. Even from the outside. For binge eating and purging to be secretive and deceitful. like stereotypes concerning people with anorexia nervosa. In addition. Whereas people with anorexia nervosa may be viewed as having a lot of self-control. people seem to understand that patients with bulimia nervosa do not enjoy their symptoms. binge eating and purging are experienced as distressing problems that the person is unable to control. However. However. and their ability to form friendships. there are people with bulimia nervosa who have difficulties in many parts of their lives.

Beth often shared clothes with her mother and would opt to wear sweaters and skirts to school instead of midriff-baring tops and hip-hugging pants. Beth was more likely to get attention from older men than from boys her own age. she did very well with her diet. She looked nice. some of whom are very similar to individuals who develop anorexia nervosa. and all of her friends told her she was pretty. That is. So. her mother had to take Beth shopping before the school year started because none of Beth’s clothes from the previous year fit her anymore. This made her feel uncomfortable about her appearance and about her weight. She lost 12 pounds (5. 31 . She wanted to lose enough weight so that she would not be able to share clothes with her mother and so that she would need to get new (preferably more fashionable) clothes for the upcoming school year. CASE STUDY 1 Beth was slightly overweight as a child. She was never so heavy that she was called “fat” or teased about her weight.4 kg) and dropped from a size 12 to a size 6. Bulimia nervosa is a heterogeneous disorder. Instead. and so was her goal. Beth started her diet during the summer before 8th grade. Because of her size. it affects a broad range of people.Bulimia Nervosa and urges to find immediate gratification or escape. Beth’s new clothes were very similar to the styles her friends wore. some of whom are very different from people with anorexia nervosa. and many of whom are similar to people who never develop an eating disorder at all. she decided to go on a diet that she read about in a magazine. she couldn’t wear the same kinds of clothes that her friends wore. but she also looked “old. as she approached adolescence. The diet seemed fairly straightforward. However. Just as Beth had planned.” When she went to the mall. she felt that she wasn’t attracting the attention of boys like her friends were. At first.

Eventually. though. she binged again. This time. so she didn’t have any kind of practice after school. The school year was off to a great start—with one exception. she wasn’t supposed to eat anything between lunch and dinner. So. This had been easy to do during the summer. but no one noticed. she felt like she had escaped from a horrible mistake she had made (and would never make again). Beth thought she would never let it happen again. and her clothes felt too tight. according to her diet. Beth was hungry and bored. As she flushed the toilet. she had two hours to herself before her parents got home from work. but she was wrong. Instead. She didn’t play on a sports team and she wasn’t a cheerleader. When Beth got home from school that afternoon. Then she panicked. Beth felt desperate to undo what she had done.32 Eating Disorders Beth was pleased by the attention she received on the first day of school and by the similarity between her outfit and that of one of her most popular friends. was everything she had just eaten. She had never eaten so much food at one time. There. She felt bloated. The next week. She brushed her teeth and cleaned the bathroom to remove any evidence of what had happened. Beth broke down and ate an entire package of cookies and two big bowls of ice cream. She waited for her parents to comment on the missing cookies or ice cream. she went out and replaced the . she would go home and watch television. in the toilet. This made her want to snack. One of the boys in Beth’s homeroom even asked what other classes she was in that year. But it was very hard after school began. She went to the bathroom and vomited. Beth didn’t have any homework. She felt like she was going to be sick. Beth knew that her parents would notice another package of cookies missing and another gallon of ice cream nearly empty. However. and the commercials kept showing food.

to the local fast-food fried chicken and biscuit chain. funny. She told herself that if her weight went beyond a size 12. She took drugs. Her mother didn’t care. at night. Beth found that she could not keep herself down to a size 6. And she had an eating disorder. and she took large amounts of diet pills. Nina didn’t eat before 8:00 P. To stay thin. CASE STUDY 2 Nina was a walking “after-school special. and laxatives. The only things that Nina did to maintain her health were drinking sports 33 .Bulimia Nervosa foods she had eaten. she vomited almost everything she ate. and nice. Beth seemed smart. To other people. she would try to stop on her own. The guys often joked that they didn’t know how one person could eat and drink so much and stay so skinny. Nina would show off her appetite by finishing her dinner as well as any food that the guys didn’t finish from their own meals. The group would order a 12-piece dinner for each person. She cut school.M. She did not drive safely. and the guys would pay for Nina’s if she ate the whole thing. Unfortunately. The convenience store on the corner became the supplier for her binge episodes. but Beth cared. She even cut herself. She tried to go back on her diet. she slept with boys and did not practice safe sex. but she could not stop binge eating. Otherwise. diuretics.” She did everything that teenage girls were warned not to do. going out to replace the food she had eaten reminded her of all the foods she had been avoiding on her diet. Nina would go out with a group of guys at 2:00 A. Sometimes. Both her eating and her weight made her feel like a failure. and she was soon wearing her mother’s clothes again.M. then she would tell someone about her problem. her friends didn’t care.

many of Nina’s behaviors are so dangerous that it might be more urgent to address some of her other patterns (such as cutting. Her breath often stank from a combination of cigarettes. Both place undue emphasis on the importance of weight and shape. However. coffee. for Beth. The back of her hand was callused from scraping up against her teeth when she would gag herself to vomit. and cavities. at the age of 19. In addition. the factors that appear to have contributed to the onset of bulimia nervosa appear to be relatively clear. However. unsafe sex. Nina looked like she was 42. The rest of this chapter will use the cases of Beth and Nina to describe the effects of bulimia nervosa and to show how to recognize when bulimia nervosa is occurring in others.34 Eating Disorders drinks to keep her electrolytes balanced and taking a multivitamin to replace what she didn’t get from food. And it is not clear why things have gone so far out of control in Nina’s life. The stories of Beth and Nina present very different pictures of bulimia nervosa. Her teeth were stained brown where they weren’t black from decay. In contrast. Her eyes were bloodshot. Both young women suffer from binge eating episodes. vomit. Her skin was tinged with yellow and was sunken around her eyes and cheeks. Although Nina always said that she was just trying to have a good time. . It would be difficult to attribute Nina’s problems to her binge eating and purging because the eating disorder seems to be part of a larger problem that is endangering Nina. The disorder has not impacted her grades or her relationships with other people. bulimia nervosa represents a relatively narrow problem within her life. she looked and felt miserable. and drug use) before worrying about her eating disorder. and both purge in response to these episodes to control their weight.

tooth decay is a common problem among people who use self-induced vomiting to counteract the effects of binge eating. and behaves.2). bulimia nervosa affects how an individual feels. Some of the physical effects of bulimia nervosa are evident in Nina’s case. For example. and it impacts physical health and how the person gets along with others. this can cause a loss of teeth. Because of this swelling. they are more afraid of gaining weight or becoming fat than of damaging their bodies. thinks. and heart function. Patients with bulimia nervosa are at particular risk for very low 35 . In most cases. Over time. near the jaw line. This stomach acid eats through tooth enamel and leaves teeth vulnerable to the effects of harmful bacteria. Physical Effects of Bulimia Nervosa Many of the physical effects of bulimia nervosa are caused by the use of inappropriate compensatory behaviors—particularly purging.1) and lead to esophageal tears.Bulimia Nervosa EFFECTS OF BULIMIA NERVOSA Like anorexia nervosa. K+) through vomit causes electrolyte imbalances that can cause problems with kidney. Vomit brings stomach acid into the mouth. then he or she would be diagnosed with the binge/purge subtype of anorexia nervosa). The parotid glands are located on both sides of the face. people who frequently self-induce vomiting often have unusually round-looking faces and “chipmunk-cheeks. intestinal. people who have bulimia nervosa are aware of the effects that their disorder has on their physical health. Repeated vomiting can cause the salivary glands (parotid glands) to swell (Figure 3. The stomach acid in vomit can also eat through the lining of the esophagus (Figure 3. bulimia nervosa does not result in low body weight (if the person had low body weight. and some people with bulimia nervosa eventually need dentures.” The loss of stomach acid (which is high in potassium. Unlike anorexia nervosa. However.

36 Eating Disorders Figure 3. blood levels of potassium. This is a very dangerous condition that requires immediate medical attention to prevent sudden death from heart failure. The stomach acid in vomit can eat through the lining of the esophagus and lead to esophageal tears. called hypokalemia. Stomach acid also eats through tooth enamel and leaves teeth vulnerable to harmful bacteria. .1 The physical effects of bulimia nervosa are mainly caused by purging.

people who use laxatives often find that they have to take more and more to produce the desired effect. they often 37 . In addition. if they try to suddenly stop using the laxatives. In addition.2 Enlarged parotid glands are often caused by repeated vomiting.Bulimia Nervosa Parotid gland Normal Parotid Glands Swollen gland Enlarged Parotid Glands Swollen gland Figure 3. The abuse of laxatives and diuretics also causes electrolyte imbalances. laxative abuse causes a loss of intestine motility. This means that the intestines lose their ability to contract and move the bowels to produce bowel movements. As a consequence.

people who engage in repeated binge episodes are less likely to feel full when they eat a normal amount of food. binge episodes have caused death by gastric rupture—the stomach literally splits open due to overeating and then the person bleeds to death internally. In addition to the obvious damage to the skin. In very rare cases. increased risk of infections. One result of a larger stomach capacity is decreased satiety function. inability to heal. Both laxatives and diuretics contribute to dehydration. coma or death can occur. This probably increases the risk for binge eating episodes. Over the long term. A particularly dangerous form of purging occurs among individuals with bulimia nervosa who also have insulin-dependent diabetes mellitus. and water retention is a common side effect after stopping laxative and diuretic use. However. bulimia nervosa also appears to increase . and loss of limbs through amputation. resulting in increased stomach capacity. That is. loss of kidney function. When a lack of insulin is combined with bingeeating episodes on high sugar foods.3). the use of fingers or any other instrument to force a gag reflex may lead to tears in the esophagus (Figure 3. These people may try to avoid weight gain by reducing or eliminating their insulin doses. This causes hyperglycemia. The repeated rubbing of the back of the hand against the upper teeth to induce vomiting causes these calluses. Another physical effect of bulimia nervosa is skin problems. congestive heart disease. Emotional Effects of Bulimia Nervosa Emotions certainly contribute to the development of bulimia nervosa.38 Eating Disorders experience constipation. sustained hyperglycemia leads to blindness. Nina has calluses on her hand because she uses her fingers to gag herself. Binge eating causes the stomach to stretch.

Bulimia Nervosa 39 How Bulimia Affects the Body Brain Depression. diarrhea. heart failure. delayed emptying. Intestines Constipation. gum disease. This shame results . anxiety. heart muscle weakened. pain. shame. blood in vomit. can tear and rupture. fear of gaining weight. the use of fingers or an instrument to force a gag reflex may cause tears in the esophagus. bloating. Hormones Irregular or absent period. irritated. teeth sensitive to hot and cold foods. soreness.3 Bulimia affects the body in many ways. emotional distress. low pulse and blood pressure. In addition to skin damage. Anemia Heart Irregular heart beat. and sodium. those who have the disorder often feel a great deal of shame. Figure 3. Body fluids Dehydration. low self esteem. dry skin. Muscle fatigue Stomach Ulcers. Cheek Swelling. Mouth cavities. Because of the negative way other people react to the symptoms of bulimia nervosa. Skin Abrasion of knuckles. Throat & Esophagus Sore. dizziness. magnesium. low potassium. tooth enamel erosion. can rupture. irregular bowel movements. abdominal cramping.

For one. Diana developed bulimic symptoms shortly after her engagement to Prince Charles. You fill your stomach up four or five times a day—some do it more—and it gives you a feeling of comfort. Diana was at the peak age for the onset of bulimia nervosa. Her engagement brought a great deal of media attention. According to Diana. and that is frightening. this loss of control is very inconsistent with how they normally feel. Bulimic patients often say that they feel like they might as well throw the food into the garbage. when she was only 19 years old. caused enormous stress and limited options for coping with that stress. Diana.40 Eating Disorders from different aspects of the disorder. Binge episodes also contribute to fears of gaining weight or becoming fat. In an interview with the British Broadcasting Corporation (BBC) given in 1995. You inflict it upon yourself because your self-esteem is at a low ebb. and you don’t think you’re worthy or valuable. Then. Princess Diana Among the many famous people who have suffered from bulimia nervosa. According to interviews she gave. there is the waste of huge amounts of food. And that’s like a secret disease. but it’s temporarily. It’s like having a pair of arms around you. At 19. Princes of Wales was perhaps the bestknown. temporary. like Beth. For some. since it ultimately gets flushed down the toilet. there is the sense of gluttony. People with bulimia nervosa also feel acutely aware of their inability to stop themselves from bingeing. combined with the pressure of joining one of the most famous families in the world. her symptoms grew worse after her wedding. Diana described her illness: I had bulimia for a number of years. Then you’re disgusted . This.

However. [ . Available online at http://www. later. so—and people think you’re wasting food—so you don’t discuss it with people. Source: Bashir. And it’s a repetitive pattern which is very destructive to yourself.html. And the thing about bulimia is your weight always stays the same. . you have to know that when you have bulimia you’re very ashamed of yourself and you hate yourself. they believe they will be able to stop on their own and. This excerpt reveals the vicious cycle in which many people with bulimia find themselves trapped.” 1995. So you can pretend the whole way through. 41 . There’s no proof. The emotional effects of vomiting increase the likelihood that the person will intentionally vomit again the next time he or she engages in a binge. at first.org/wgbh/pages/frontline/shows/royals/interviews/bbc. . and then you bring it all up again. purging eliminates only a small portion of food consumed and is not an effective means of weight control. “Interview with Princess Diana. In addition. Martin. but then cause additional distress and a further loss of self-worth. whereas with anorexia you visibly shrink. because they feel ashamed of their illness. people with bulimia nervosa express feelings of intense anxiety that are only eased once they have “undone” the damage of their binge episode by purging what they have eaten. Binge eating and purging serve as a way to cope with distress.Bulimia Nervosa After a binge. many people delay getting help because.] You. the knowledge that they have a way to “get rid” of the food eaten during a binge episode at the bloatedness of your stomach. Although medical treatment can be very effective in helping people recover from bulimia nervosa.pbs.

For example. However. her academic problems appear to be part of a larger pattern of issues with impulse control that likely caused her eating disorder (rather than being caused by her eating disorder). plan. Although Nina has clear problems with her school performance because of her truancy. patients with bulimia nervosa rarely express disgust toward food. this is not directly related to her eating disorder. a person with bulimia nervosa is not able to avoid these foods entirely. However. people with bulimia nervosa appear to maintain their ability to remember. Bulimia nervosa does impact thoughts surrounding food and weight. As we saw. Instead. concentrate. people with bulimia nervosa are likely to engage in cognitive distortions that help them maintain their illness. Cognitive Effects of Bulimia Nervosa One interesting aspect of bulimia nervosa is its ability to leave cognitive functioning largely intact. Specifically. showing no outward sign of her inner turmoil. bulimia nervosa is not associated with any impairment in school or work function. During particularly severe binge eating episodes. patients may become so caught up in the process of bingeing that they will consume unusual foods (such as condiments or orange or banana peels) after they run out of regular food.42 Eating Disorders makes it harder for people with bulimia nervosa to avoid binge eating. they do express disgust toward themselves and toward their bodies. . Moreover. high-fat or high-sugar/high-carbohydrate foods are considered “bad” and are avoided. think. for example. These labels are often related to the nutritional properties of food. Beth appears to be able to balance her lifestyle perfectly. and execute their plans. That is. Unlike patients with anorexia nervosa. a person with bulimia nervosa may categorize all foods as either “good” or “bad” ( “safe” or “dangerous”).

that one “mistake” is enough to deem the whole day a failure. you could never eat another potato chip or cookie for the rest of your life. to some extent. This appears to be triggered. Because people with bulimia nervosa are almost constantly trying to follow strict diets. given the social nature of food. People who are attempting to hide the fact that they are engaging in large binge episodes and purging are forced into awkward situations. that food becomes even more tempting and desirable. a piece of cake at a friend’s birthday party). it is also forbidden. This kind of black-and-white thinking (called dichotomous thinking) increases the likelihood of binge eating. Behavioral Effects of Bulimia Nervosa For people who are trying to hide their eating disorder.Bulimia Nervosa When he or she eats a single bad food (for example. then why not eat the whole cake? For many people. the answer is that they would not want a whole cake. For people with bulimia nervosa. 43 . for fear of having a binge episode. in addition to tasting good. by the constant use of dietary restrictions. they convince themselves that they will never eat another chip or cookie (or whatever their favorite. You might decide that it would be worth it to try to have your fill tonight so that you would never want another cookie. most fattening food may be). In a sense. Imagine that you were told that. the whole cake may serve as just the beginning for a binge episode in which they let themselves go completely. this is the thought process for a person who has bulimia nervosa. They may make up reasons to avoid attending dinners or parties. If eating one piece of cake is as bad as eating an entire cake. the greatest behavioral impact of bulimia nervosa is its impact on honesty. because. People with bulimia nervosa will also sometimes feel compelled to “get rid of ” normal-sized meals. starting tomorrow. however. Once they declare that they will never eat a certain food again.

people with bulimia nervosa believe that others will judge them extremely harshly for their behavior. A meal may not necessarily be excessive. Interpersonal Effects of Bulimia Nervosa People with bulimia nervosa often report having interpersonal difficulties. It is hard to tell whether this is a cause or an effect of the eating disorder. Often. The need to be alone to engage in bulimic behavior can interrupt their participation in social events. Since they don’t allow others to know about and react to the eating disorder. As a result.44 Eating Disorders The constant pattern of dieting and the attempts to make up for failures to stick to the diet leads the person to see even normal meals as excessive. The secretive nature of the disorder can drive a wedge between people with bulimia and others because the person with the disorder knows they are hiding something from friends and relatives. People cannot simply tell a dinner host or fellow guests that they need to use the restroom to vomit up their meal. in a social setting. as they have to excuse themselves for as long as they need to purge and then get rid of any evidence of purging. The reason some experts believe it is an effect is that people generally do not engage in bulimic behaviors in front of others. This type of dishonesty is closely related to the emotional and interpersonal effects of bulimia nervosa. Thus. . but it does exceed what the person planned or hoped to eat. patients may imagine the social rejection and isolation that might result would be much worse than would be the case if they asked for help. the frequency of binge eating and purging episodes dictates how often a person with the disorder will need to be alone. the person may feel intense anxiety after eating a normal amount of food—an anxiety that he or she knows can be eliminated only by vomiting. so they must come up with other plausible explanations for their sudden disappearance from the dinner table.

Other signs of bulimia nervosa include skipping meals and excessive exercise routines.Bulimia Nervosa RECOGNIZING BULIMIA NERVOSA Because most people with bulimia nervosa have a normal body weight. Alternatively. 45 . However. In a person of normal weight. these types of behaviors may not cause much concern. this suggests that he or she is consuming most meals alone. under that flat surface there may be a cavern from which ice cream has been precisely scooped. and pies may be recut to give them their original appearance. Brownies. a carton of ice cream may appear to have a relatively smooth surface. if a person seems to avoid eating meals with other people yet retains a normal body weight. If you live with a person with bulimia nervosa. For example. there is no outward physical sign of the disorder. For example. there are behavioral signs of the disorder. Although people may eat normal meals by themselves. if it seems that a person spends too much time exercising and never seems to eat. it may seem like food supplies are reduced in ways that are designed to prevent anyone from noticing that food is being eaten. since both fasting and exercise can be ways people try to counteract the effects of binge eating. while the equivalent of several pieces has actually been removed. However. you may notice that food disappears without explanation. However. it is also possible that they choose to eat alone so they can prevent others from seeing what and how much they eat. cakes. Long bathroom visits may also be the result of attempts to rid the bathroom of the smell of vomit or may be caused by the effects of laxatives on bowel movements. If a person makes frequent visits to the bathroom—particularly to brush his or her teeth—this may be a sign of attempts to mask the smell of vomit on the breath. then he or she may follow a pattern of engaging in one large binge and then compensating for it with exercise and fasting.

Clearly. Some people in the United States may choose to skip breakfast and just eat lunch and dinner (a two-meal pattern). In fact. and dinner). with the last meal usually being the largest. there may be a great deal of normal variation within a culture. In Spain. It is more likely that a person will become suspicious that someone has anorexia nervosa without ever speaking directly . Different people follow different eating patterns. it is important to remember that suspicions of an eating disorder are just that—suspicions. it can be tough to uncover abnormal patterns among normal variation. no single society’s eating patterns is necessarily “natural. There may be other reasons behind behavior that resembles that described above. smaller dinner and reduces the tendency to eat an afternoon and evening snack. In England. The evening meal is light.” As a consequence. we usually follow a three-meal-perday pattern (breakfast. In the United States. Many people eat snacks between meals. it is important to take great care in responding to suspicions that a person may have bulimia nervosa. the midday meal is the largest. This late afternoon meal allows for a later. these meals are supplemented by another meal (called tea) in the late afternoon. followed by both evening and then mid-morning snacks. it is so large that people take a period of rest (called a siesta) after eating it. The best way to appreciate how much variability exists in normal eating is to look at eating patterns in different cultures. Because of this variation. Therefore. Others may choose to eat three small meals and three snacks (a six-small-meal pattern). lunch. similar to the evening meal in other European countries. with midafternoon snacks probably being the most common.46 Eating Disorders • • • • • • • SUMMARY As we discussed in Chapter 2.

You should be honest with your friend that you cannot keep this information secret because of the health risks associated with your friend’s behavior. the person who has the disorder will often confide about binge eating and purging to an unsuspecting friend or relative. Sometimes. If you learn that a person has an eating disorder and you do nothing. the person’s confession will come with requests that the information be kept strictly confidential. it would be better to talk to someone who will keep the information confidential and who is trained to help individuals in need. Instead. the person may take this as permission to continue the dangerous behavior. This is unhealthy both for you and for the person with the eating disorder. with bulimia nervosa. 47 .Bulimia Nervosa to the affected person. In contrast. such as a school counselor or nurse. because it is a request to take some of the anxiety the person is feeling about the eating disorder upon yourself. This is an unreasonable request.

or disability. is a specific type of EDNOS. pain. loss of freedom. In the case of binge eating disorder. the definition for the 48 . present distress. 2.4 Binge Eating Disorder and Eating Disorders Not Otherwise Specified Most people who have eating disorders do not suffer from either anorexia nervosa or bulimia nervosa. work. or school performance). disability (defined as impairment in important life functions such as relationships with others. Any clinically significant disorder of eating that does not meet full criteria for anorexia nervosa or bulimia nervosa would be diagnosed as an EDNOS. what makes a disorder “clinically significant?” Clinical significance is defined by the presence of one of three qualities: 1. 3. Binge eating disorder. increased risk of death. These are known as eating disorders not otherwise specified (EDNOS). Anorexia nervosa and bulimia nervosa both meet the requirement of clinical significance because of their medical complications. This may seem strange. there are a lot of clinically significant eating disorders other than anorexia nervosa and bulimia nervosa. However. So. since these are often the only two eating disorders most people know about. for example.

not problems of weight. as defined above. Similarly. This is similar to people with depression feeling they cannot control being down in the dumps or people with panic disorder feeling that they cannot control their sense of anxiety. many people continue to believe that a person who is morbidly obese must have an eating disorder. If obesity is associated with an increased risk for death and represents a physical disability. people experience a loss of control during binge eating episodes (Figure 4. Otherwise.Binge Eating and Other Eating Disorders disorder actually requires that people express present distress over their pattern of binge eating. However. People often engage in unhealthy behaviors with full knowledge of how and why the behavior is unhealthy. BINGE EATING. obesity may be linked to binge eating disorder (BED) or an EDNOS marked by binge eating. AND OVERWEIGHT/OBESITY Chapter 1 discussed how eating disorders were problems of eating. Instead. there must be some sense in which the mental disorder is non-volitional. there are many behaviors that people engage in that are not healthy. What is the difference between binge eating and overeating? The answer is control. These people experience these events as something that is happening to them rather than something they are choosing to do. then this would seem to be an EDNOS. They feel they cannot control what or how much they are eating. However. This is not a sign of a mental disorder. overeating is something that almost everyone chooses to do from time to time. though. OVEREATING. obesity is a result of simple overeating. people will occasionally choose to overeat. there is one important factor to remember before you jump to this conclusion: Obesity is a consequence of something that is wrong. Overeating is not healthy—but then. For many people. In contrast. from smoking cigarettes to driving too fast to talking on a cell phone while driving. every 49 . For some people.1). By definition.

People who have BED may be less likely to respond to weight control programs and more likely to go through dramatic fluctuations . Those who have this disorder experience a loss of control during binge eating episodes. person who engages in risky behaviors would be diagnosed with a mental disorder.50 Eating Disorders Figure 4. Comparisons of obese individuals without BED and obese individuals with BED indicate that BED is associated with increased depression and dissatisfaction with the body.1 Binge eating is an example of an eating disorder not otherwise specified (EDNOS).

Ben’s reputation as a funny guy grew. however. Ben was also very funny. Ben gained 75 pounds (34 kg). He could remember eating more than anyone else in school and in camp when he was a child. Ben heard others give testimonials that mirrored 51 .Binge Eating and Other Eating Disorders in their weight. However. Thus. none of them seemed interested in being his girlfriend. In OA. Ben developed a small following and decided to drop out of college to pursue a career in comedy. and he could make teachers laugh. the only types of EDNOS a person may have. known as purging disorder. He was elected class vice president and had a leading role in the school musical. So. In college. He attributed this to a lot of beer and late-night eating at pizza places. He had always been heavy as well. Between high school and dropping out of college. CASE STUDY 1 Ben had always been a big eater. Ben was always popular in school. even though girls always wanted to be his friend. understanding whether or not a person feels control over eating holds important implications for understanding his or her psychological health and how he or she may respond to programs designed to improve physical health. He joined the staff of a humorous monthly college journal and started doing stand-up comedy on open mike nights at the local comedy clubs. Ben felt that girls didn’t find him attractive because of his weight. These are not. Not only could he make his friends laugh. Ben decided to join Overeaters Anonymous (OA) to try to lose some weight because it was free. he could make kids who didn’t even know him laugh. The following cases illustrate BED and one other possible EDNOS. but he decided that it was okay not to have a girlfriend since he was going away to college after high school anyway.

However. he described what happened. At the next OA meeting. Looking around the room. after a particularly good comedy set. from that point on. After six months of binge eating every other day. However. Ben felt like he deserved a celebration. They said that certain foods changed the way they felt and thought. like a powerful drug. Ben saw a lot of people who had lost a ton of weight by following the OA guidelines. Each meeting started with a person telling his or her story. He went out with some other comedians and ordered beers and pizza. That night. and during that time. He had never felt so free to simply “be” without being funny. and his weight crept back up and over what it had been when he joined OA. CASE STUDY 2 Pearl was a petite girl whose mother was Korean and father was American. one late night. he lost a lot of weight. and Ben found it very liberating. People talked about how they reacted to food differently from other people. . Ben consumed more beer and pizza in one sitting than he had ever eaten before. There was also a lot of support within the room as people shared their successes and failures. Ben decided to drop out of OA and seek medical help for his eating problems. Ben was able to follow the OA program for a while. and other people in the group offered their support and encouraged him to get back on the program. He had met Pearl’s mother while he was doing research in Korea.52 Eating Disorders his own life. Her mother was a stay-at-home mom and her dad was a college professor who specialized in East Asian History. He alternated between good days and days when he would binge. Ben found it difficult to resist urges to go back to his old eating habits. He felt horrified when he realized what he had done.

Ben does not engage in any inappropriate compensatory behaviors. and her mother emphasized the importance of not overeating and staying thin. It was very important to her to remain thin because she already felt uncomfortable about her height. In many respects. Pearl uses self-induced vomiting and drinks tea that acts as a diuretic and laxative. which more people would use if it occurred to them. Pearl does not seem to have any notable problems with her food intake. she never ate more than others were eating in the same situation. She would become very anxious because she was terrified of gaining weight. her weight remained within a normal range for her height. Ben cannot control what or how much he eats. Although Pearl was thin. she might eat junk food with school friends. Pearl’s mother gave her “thinning tea”—an herbal tea that had a laxative and diuretic effect. In contrast. However. Pearl discovered that the vomiting and diarrhea of her illness also made her “feel light. immediately after dinner.” She started experimenting with vomiting after meals to re-create this feeling. On the face of it.Binge Eating and Other Eating Disorders Pearl was large for an Asian girl because her father was tall. By the age of 17. Pearl felt very normal. Ben and Pearl appear to have very different problems. At most. She did not even realize that vomiting after meals was considered unusual because she felt that it was a very clever way to stay thin. so that she could go to bed with an empty stomach. She felt uncomfortable with her size. Ben is obese. The only time Pearl felt distress was when she was prevented from vomiting. but she was not overweight. Before holiday meals. After a bout of stomach flu. Pearl was vomiting once a day. Pearl 53 . This tea made Pearl feel thinner and lighter and seemed to offset the effects of holiday meals. She never had binge eating episodes.

many people who recover from binge eating disorder do not necessarily lose significant amounts of weight.1 HEALTH CONSEQUENCES OF OBESITY High Blood Pressure High Cholesterol Levels Heart Disease Diabetes Mellitus Gallbladder Disease . EFFECTS OF EDNOS The effects of EDNOS depend upon the symptoms. then the effects can be similar to those observed with anorexia nervosa. Thus. Pearl’s patterns seem to represent problems with compulsive behaviors. both have EDNOS even though their circumstances differ greatly. Table 4. Ben’s patterns seem to represent problems with impulsive behaviors. If EDNOS is associated with binge eating and purging.1). a person cannot recover fully from anorexia nervosa without returning to a normal weight. In addition. these patterns are associated with distress. In contrast. both of them engage in disordered patterns around eating that increases their risk of health problems. However. Thus. However. If EDNOS is associated with starvation. then the effects can be similar to those observed in bulimia nervosa. In the case of binge eating disorder.54 Eating Disorders is thin. some effects of the disorder are attributable to obesity (Table 4. either when they cannot avoid the behavior (like Ben) or when they are prevented from engaging in the behavior (like Pearl).

2 BINGE EATING DISORDER (BED) STATISTICS • The prevalence of BED is estimated to be approximately 1–5% of the general population. The key factors are personal distress. his eating patterns increase his risk of various medical complications related to obesity. on the other hand.Binge Eating and Other Eating Disorders although binge eating may contribute to obesity. 1998). • People who struggle with BED can be of normal or heavier than average weight. • BED affects women slightly more often than men— estimates indicate that about 60% of people struggling with BED are female. Pearl’s vomiting.1). there is no evidence of interpersonal problems. disability. • BED is often associated with symptoms of depression. • People struggling with BED often express distress. et al. and guilt over their eating behaviors. For Pearl. 40% are male (Smith. In Ben’s case. In Ben’s case. it is not the sole cause of obesity for most individuals (Table 4. he might still face these risks even if he stopped binge eating.. RECOGNIZING EDNOS Recognizing an EDNOS is probably more difficult than recognizing anorexia nervosa or bulimia nervosa. has no personal distress because of her eating. There may not be dramatic behavioral differences between a person with an EDNOS and a person who has some unhealthy but normal eating patterns. However. 55 . his distress over his pattern of eating is apparent from his attempts to seek help to change. Pearl. and diuretic Table 4. and increased risk. Ben’s pattern of eating may play a role in his ability to form relationships with others. laxative. shame.

RESPONDING TO EDNOS Responses to suspicions of EDNOS should resemble those for anorexia nervosa or bulimia nervosa. However. reactions on the The Future of Eating Disorders Not Otherwise Specified (EDNOS) Based on studies of binge eating disorder.56 Eating Disorders use put her at significant medical risk for heart.2). and intestinal disorders. The inclusion of other EDNOS as categories for further research will make it easier to characterize the full range of eating disorders from which people suffer. kidney. However. This would increase the proportion of people with eating disorders who receive an official diagnosis. However. but it would not be possible to detect Pearl’s problem unless her behavior was closely monitored after each meal to note how long she takes in the bathroom and whether she suffers distress if she cannot get to a bathroom after dinner (Table 4. Other forms of EDNOS include purging disorder and night eating syndrome. most people who suffer from eating disorders would continue to be diagnosed with an EDNOS. Night eating syndrome is similar to binge eating disorder in that people eat large amounts of food and feel a loss of control over their eating but do not engage in inappropriate compensatory behaviors. many researchers in the field of eating disorders support making binge eating disorder a fully recognized eating disorder. food consumption occurs primarily at night and is associated with disturbances in sleeping patterns. . Purging disorder occurs in normal weight individuals who purge to control their weight but do not have large binge episodes. like anorexia nervosa and bulimia nervosa.

is likely to respond well to friends’ attempts to support and help him because he is already eager to find a way to control his eating. Ben. 57 . is likely to deny that she has any problems related to food or eating and will probably avoid other people’s attempts to prevent her from purging.Binge Eating and Other Eating Disorders part of the person affected will depend greatly upon what he or she is doing. Pearl. Both cases will require patience because their patterns—while deliberate for Pearl and not for Ben—feel beyond their control. in contrast. for example.

and Pearl. and her response to binge eating was specifically motivated by a desire to avoid gaining weight.5 Causes of Eating Disorders Just as eating disorders impact a person’s physical body.M. In the case studies of Ashley. the girls all reported some level of concern about their weight or shape. Ashley began her diet and exercise regimen specifically to lose weight. In a series of clips from interviews with ten contestants. and 58 . three of them mentioned the negative effects the media had on girls’ self-esteem and their eating. and ends with a discussion of biological factors that increase risk for eating disorders. and social factors are all important in understanding the causes of eating disorders. then discusses the importance of psychological factors. Beth. Nina would not eat before 8:00 P. SOCIAL FACTORS While watching the 2004 Miss Teen USA competition. mind. This chapter begins by reviewing evidence that social factors contribute to the development of eating disorders. Beth initially went on her diet to go from a size 12 to a size 6. and social life. I was struck by contestants’ comments that they were concerned about the pressure teenage girls experience to conform to media images of the ideal body. Nina. biological. psychological. and used several methods of purging to keep her weight down.

the winner of Miss America weighed less than 78% of what would be expected for her height. Playboy magazine. A number of experimental studies have examined the impact of thin media images on women’s body image. From 1959 to 1978. Garner and his group concluded that increasing rates of anorexia nervosa were a consequence of America’s increasing obsession with thinness. and women’s magazines (Harper’s Bazaar. These trends have continued into recent years. and Woman’s Day). Kevin Thompson recruited female participants for a study on the effects of media images on body perception at the Johns Hopkins University School of Medicine. During the same period of time. they examined time trends for three different sources of information about beauty ideals: the Miss America Pageant. anorexia nervosa and bulimia nervosa became more common during the second half of the 20th century. At the Clarke Institute of Psychiatry. Playboy centerfolds became thinner as well. in the last year they examined. David Garner and colleagues hypothesized that the increase in rates of anorexia nervosa reflected an increasing idealization of thinness for women. Finally. Ladies’ Home Journal. Leslie Heinberg and J.7 Participants were randomly assigned to view either television commercials 59 . McCall’s. and their overall figures shifted from a womanly hourglass shape to a more adolescent tubular shape. Recall that deliberately maintaining a weight less than 85% of what is expected for height is the first criterion for a diagnosis of anorexia nervosa.Causes of Eating Disorders Pearl felt that she had to vomit after eating normal amounts of food to stay thin. Good Housekeeping. Vogue. In fact. Based on these trends.6 To test their hypothesis. they found that both Miss America contestants and winners became increasingly thinner. the number of articles on weight loss diets doubled in popular women’s magazines. To what extent are eating disorders caused by the desire to achieve a thin physique? As described in Chapter 1.

Women who viewed appearance-related commercials reported significantly greater body dissatisfaction after seeing the commercials compared to women who saw non-appearance-related commercials. average-sized models. Notably. however. and said that they had a desire to be thin. neither study demonstrated that these images directly cause eating disorders. Both studies provided evidence that media images portraying the thin ideal contribute to body dissatisfaction. dieting. At Arizona State University. A recent study looked at how television affected the beliefs. Self-induced vomiting to control weight increased from 0% of girls at the start of the study to 11% of girls three years later. the new group of Fijian girls reported beliefs that success. after much more exposure to television. Given that the ideal female body is much thinner than most women’s bodies are naturally.8 Women who saw pictures of very thin models reported significantly greater body dissatisfaction than women who saw pictures of average models or no models. and behaviors of girls in Fiji. At the start of the study. or no models. girls reported very little body dissatisfaction. Follow-up assessments were conducted three years later with a new group of girls. values. and did not report that being thin was important. Eric Stice and Heather Shaw randomly assigned women to view magazine pictures of very thin models. or purging.60 Eating Disorders that contained appearance-related images or television commercials that did not contain appearance-related images. and independence were related to being thin. it is not surprising that most women feel dissatisfied with their weight and have attempted to . Three years later. wealth.9 Assessments were conducted within one month of the time that televisions were placed in the homes of Fijian girls. This was consistent with traditional Fijian cultural values. This study provided strong evidence that the introduction of the thin ideal is associated with the development of eating disorders.

63% reported that they are currently attempting to lose weight. but only 43% described themselves as currently overweight. 76% reported dieting at some point and 76% reported desiring to lose weight currently. as in Ashley’s case.10 and 73% reported trying to lose weight in the past. When dieting contributes to binge eating. but otherwise remained on the diet. by eating a piece of birthday cake at a friend’s party. For most people. Now. as it did for Beth. PSYCHOLOGICAL FACTORS If three-quarters of college women have tried to lose weight by dieting and most were normal weight when they started their diets.11 Among college women. and how much she should eat. as seen in Beth’s case. then anorexia nervosa may develop. the vast majority of girls who attempt to lose weight do not develop anorexia nervosa.Causes of Eating Disorders lose weight by dieting. if a person simply deviated from the diet slightly. Dietary rules replace physical sensations such as hunger and satiety in determining food intake. Why would attempts to restrict food intake result in the exact opposite behavior? Dieting and Binge Eating When a person goes on a diet. Among high school girls. then why isn’t anorexia nervosa more common? Recall that anorexia nervosa only affects about 1 in 100 women. diets lead to initial weight loss. Clearly. she uses the diet to decide what she should eat. as in Beth’s case. then bulimia nervosa may develop. for example. When dieting leads to significant weight loss.12 Girls who diet are eight times more likely to develop anorexia nervosa or bulimia nervosa than girls who do not diet. and binge eating causes weight gain. and only 3% were actually overweight. when she should eat. then 61 . However. most people eventually break their diets. One reason for this is that dieting contributes to binge eating.

three handfuls of candy.13 When a rule was broken. after eating a piece of cake. there was no difference between a slight deviation (one piece of cake) and a huge deviation (two pieces of cake. Why would a person do this? Janet Polivy and Peter Herman from the University of Toronto argued that dieters replaced physical cues for eating with cognitive rules about eating.62 Eating Disorders the person would still be eating less than normal. these studies show that a . When asked to consume nothing prior to the taste test. or some crackers and cheese.” however. some candy. Thus. Thoughts about eating (cognitions) acted to release dietary restrictions (disinhibition). and as long as the rule was broken. Some people eat much more. some potato chips. However. A broken rule was a broken rule. individuals will be asked to participate in a “taste test. his or her weight would be lower than it would be if he or she were not dieting. a bowl of potato chips. and continue to eat until feeling stuffed. dieters consume a lot more during the taste test than nondieters. consistent with their being on a diet. The classic design compares responses to experimental manipulations in individuals with high versus low scores on a measure of dietary restraint. half a plate of cheese and crackers). For example. this is not what typically happens when people break their diets. Polivy and Herman referred to this phenomenon as cognitive disinhibition. As a consequence. This effect has been demonstrated and replicated by a number of labs. the person might as well enjoy all of the foods forbidden by their diet. dieters consume less than nondieters. Many people respond by eating more than they would normally eat. When asked to consume a milkshake prior to the taste test. For example. prior to this they are randomly assigned to consume a milkshake or nothing (the experimental manipulation). These researchers and others have conducted numerous experimental studies that support this hypothesis. the person might have a second piece of cake.

give people the opportunity to eat almost unlimited amounts of delicious foods. Essentially. These treatments have proved highly successful in eliminating 63 . or angry. When the food is gone and eating stops. Cognitive behavioral therapy for bulimia nervosa prescribes a pattern of regular eating of three meals and three snacks per day so that patients eat something every two to three hours. the person bingeing is left with the realization that he or she has lost control over eating. this feeling generally fades when the frequency of binge/purge episodes increases and the realization that the pattern is beyond their control sets in. In addition. when using drugs or alcohol. Although binge eating episodes offer a temporary release from dietary restriction. binge episodes also cause a lot of distress once they are over. anxious. Purging and other compensatory behaviors are designed to undo these negative effects of binge eating episodes. and can help some individuals “zone out” when they are feeling depressed. Purging has the immediate effects of relieving anxiety and stomach discomfort. which leads to feelings of helplessness.Causes of Eating Disorders milkshake will cause a dieter to eat an unusually large amount of food. or when feeling emotionally overwhelmed. there is terror over the effects that the binge will have on body weight and shape. However. anything that challenged a dieter’s ability to follow the diet left him or her vulnerable to a complete loss of control over eating. the initial cycle often does not seem very bad. For a lot of patients who develop bulimia nervosa. resulting in a binge eating episode. Polivy and Herman argued that binge episodes were triggered when dieters encountered cognitive disinhibitors. and self-loathing. disgust. and so they encourage patients to stop dieting. Many patients describe feeling that their binge/purge cycles are a perfect solution for an otherwise impossible problem. Treatments for bulimia nervosa have used the premise that dieting causes binge eating.

and perfectionism. in a subset of individuals. then why don’t more people suffer from bulimia nervosa and binge eating disorder? Bulimia nervosa only affects about 1 in 33 women. Those who are depressed often feel that they are not smart enough. and. feeling overweight may be just one of several ways that a depressed person feels inadequate. far less than the 3 out of 4 who have dieted at some point in their lives. The personality features that are associated with the risk of binge eating are negative emotions. social enough. anxiety. Focusing attention on a perceived weight problem may give the person a false sense of control. by controlling weight and body shape. and low self-esteem. Thus. or attractive enough. Why would depression lead to body dissatisfaction? First. which suggests that body dissatisfaction may emerge as a consequence of depression. dieting does not cause binge eating in all people. Interestingly. Studies have shown that a tendency to have these negative emotions predicts the future development of eating disorders.64 Eating Disorders binge eating episodes and helping patients recover from bulimia nervosa. . If dieting causes binge eating. This has been attributed to their increased tendency to experience negative emotions such as depression. depression emerges in people who feel that they are lacking in some way. Clearly. Researchers have suggested that certain personality features determine whether dieting will increase the risk of binge eating. levels of body dissatisfaction are more strongly associated with depression than they are with bulimic symptoms. Personality and Eating Disorders Most people who suffer from eating disorders also suffer from depression. may then contribute to the development of an eating disorder. impulsiveness. He or she may come to believe that. he or she will feel better.

Bruch’s patients experienced significant anxiety. perfectionism may increase risk of developing both eating disorders. regardless of the long-term consequences. Drew Westen and Jennifer Harnden-Fischer at Boston University reported that a high-functioning/perfectionistic personality style was present in both anorexia nervosa and bulimia nervosa. and sexual promiscuity). Perfectionism likely increases risk for eating disorders by 65 . and concern about disappointing others. In contrast to early clinical descriptions of anorexia nervosa.Causes of Eating Disorders Hilde Bruch of Baylor College of Medicine noted that many of her patients with anorexia nervosa tended to be straight-A students with many accomplishments. Nina does not seem to care about her own safety. her eating disorder seems to be just one more expression of her problems with impulse control and selfregulation. She only seems to care about seeking immediate pleasure in her life. or be sexually active— suggesting that they have higher levels of constraint. In many ways.15 Much of this is apparent in Nina’s case. In contrast to their happy external appearance. Perfectionism combined with inhibition may contribute to developing restricting anorexia nervosa. However. they hid their negative feelings. while an impulsive/emotionally dysregulated personality is characteristic of binge eating in both anorexia nervosa and bulimia nervosa.14 In addition. stealing. depression. Many of these features can be seen in Ashley’s case. Perfectionism combined with impulsiveness may contribute to the development of bulimic symptoms.16 Thus. and poor social adjustment. Before the onset of their illness. having problems with social anxiety. they were less likely to drink alcohol. use drugs. Research has supported that a constricted/overcontrolled personality is characteristic of restricting anorexia nervosa. Gerald Russell characterized patients with bulimia nervosa as having antisocial behaviors (abusing drugs. sadness.

Foods are seen as either good or bad. combined with low self-esteem and a belief that one is overweight. Perfectionism increases selective abstraction—a cognitive distortion in which part of something comes to stand for the whole. has been shown to predict future development of bulimic symptoms. have become more common over recent years. BIOLOGICAL FACTORS Because eating disorders affect mostly women. social factors have been given the greatest emphasis in their etiology. a person may believe that because her thighs are too fat. Because only a very small number of girls in modern Western societies develop eating disorders. For example. even if her body is actually emaciated. Losing weight is good. Perfectionism. What makes a person perfectionistic? Why is one person vulnerable to feeling depressed and anxious while another feels secure and happy? Why did Ashley feel that she needed to cheat on her exam in order to do well? Why does Nina crave danger? Why does Ben have urges to eat such large amounts of food? Genes and Eating Disorders Early explanations for psychological factors focused on people’s . no matter how emaciated the person becomes. Many of the thought processes that contribute to eating disorders likely arise from perfectionism.66 Eating Disorders contributing to dichotomous thinking—the kind of black-andwhite thinking described for when people break their diet. her entire body is too fat. and gaining weight is bad. and are more common in Western nations. Individuals with eating disorders tend to score higher on measures of perfectionism compared to individuals who do not have eating disorders. researchers increased their focus on psychological factors that might make one individual more vulnerable to cultural messages compared to another individual.

Molecular genetic studies identify the specific genes that may increase risk for developing eating disorders. different combinations of alleles for a given gene) can range from differences in eye color to differences in risk for developing an eating disorder. more recent research has begun to examine not only the contribution of family to rearing environments but also the genetics of children in determining psychological makeup. a gene could code for eye color. one way to identify specific genes is by using a candidate gene study. These studies provide clear evidence that genes play an important role in the development of eating disorders. One approach to disentangling the effects of rearing environments from genes is to use twin studies. For a given gene. this results in a homozygous genotype. Population-based twin studies have shown greater similarity between identical twins for personality features.1). For example. When the alleles received from each parent differ. whereas fraternal twins (dizygotic twins) are not genetically identical. and eating disorders than between dizygotic twins. When the alleles received from each parent are the same. Allele refers to one of several forms of the same gene.. Candidate gene studies compare the frequency of alleles for specific genes (“candidate genes”) between individuals affected with a disorder and those unaffected. Eating disorders are phenotypes in studies of their getetic bases. The resulting combination of alleles for a given gene is called a genotype. For example. The observable manifestation of a genotype is referred to as a phenotype. children receive a single allele from each parent.Causes of Eating Disorders childhood—how did their parents raise them? However. If individuals with eating 67 . A gene is a sequence of deoxyribonucleic acid (DNA) that codes for proteins. Identical twins (monozygotic twins) have the exact same genetic material. weight.e. The effects of different genotypes (i. this is referred to as a heterozygous genotype (Figure 5.

There are four variations of gene pairs for the blue/brown-eyed trait.1 The Punnett Square is a tool used to determine the possible traits that two parents will pass on to their offspring. each has two copies of the gene (one on each chromosome). Such studies suggest that . disorders are more likely than individuals without eating disorders to have a specific allele or genotype. The combination that the individual receives will determine his or her eye color. or bb (homozygous recessive). An individual can have a genotype of BB (homozygous dominant). Bb (heterozygous). Since each individual has one pair of each chromosome.68 Eating Disorders Mom's Genotype (Homozygous) b b Genotype = Bb Phenotype = brown eyes Genotype = Bb Phenotype = brown eyes Genotype = bb Phenotype = blue eyes Genotype = bb Phenotype = blue eyes B Dad's Genotype (Heterozygous) b Figure 5. then this supports an association between the function of this candidate gene and risk for developing an eating disorder.

weight. 69 . they share 100% of their genes. Because monozygotic twins come from one fertilized egg that has split in two. and appetite. neurotransmitters influence how the brain works. Twin studies examine the similarity within twin pairs for a characteristic (such as a personality feature. on average. then the similarity is attributed to genes. That means that dizygotic twins are just like regular siblings who have been born at the same time and share. sleep. then the similarity between twins is attributed to their shared environment. In contrast. If monozygotic twins show greater concordance for a disorder compared to dizygotic twins. If twin concordance is similar between monozygotic and dizygotic twins. or a disorder).17 Serotonin Function in Eating Disorders Serotonin (also called 5-hydroxytryptamine. Neurotransmitters are chemicals that facilitate communication between brain cells (neurons).Causes of Eating Disorders genes may contribute to eating disorders by impacting serotonin function. increased 5-HT activity in a Twin Studies Twin studies take advantage of the natural occurrence of two types of twins—identical (monozygotic) and fraternal (dizygotic). Specifically. or 5-HT) is a neuro- transmitter that influences mood. dizygotic twins occur when two separate eggs have been fertilized by two different sperm at the same time. So. then both members of a twin pair will share 100% of their rearing environment (called their shared environment). When twins are raised by their biological parents. Twin concordance is the similarity within twin pairs. 50% of their genes.

70 Eating Disorders Figure 5. hippocampus. and hypothalamus. part of the brain called the medial hypothalamus decreases food intake (Figure 5. Specifically. sleep. and appetite. Serotonin is made in a small group of brain areas and is carried to other areas of the brain such as the cortex. research on bulimia nervosa has focused on the possibility that inadequate 5-HT . Because mood and appetite are altered in patients with eating disorders. 5-HT became a prime candidate in attempting to understand the biological causes of anorexia nervosa and bulimia nervosa.2 Serotonin (also called 5-HT) is a neurotransmitter that influences mood.2). Increased 5-HT activity in the hypothalamus decreases food intake.

18 Dieting was thought to contribute to carbohydrate craving because many weight loss diets of the 1970s emphasized restricting carbohydrate intake. compared with women who did not stop their binge/purge cycles spontaneously. Diets that diminish tryptophan intake decrease 5-HT production in the brain. Walter Kaye and colleagues at Western Psychiatric Institute and Clinic found that cessation of binge/purge episodes among women with bulimia nervosa appeared to be related to the extent to which binge episodes increased tryptophan in their blood. Thus. dieting may cause 71 . and chips) were thought to represent an attempt at self-medication for low 5-HT function.19 Women who reached their “desired effect” spontaneously stopped within one to three binge/purge cycles and demonstrated greater increases in tryptophan. and recent research on anorexia nervosa has focused on of the idea that too much 5-HT explains self-starvation. Participants with and without bulimia nervosa demonstrated similar changes in blood concentrations of tryptophan. and urges to eat following tryptophan depletion. Binge eating episodes that consist of high-carbohydrate foods (such as cookies. cakes. Supporting this hypothesis. Research participants were given a liquid meal that caused a significant decrease in their tryptophan levels. anxiety. An early hypothesis proposed that inadequate 5-HT function produced “carbohydrate craving” that caused binge-eating episodes. More recent research has examined emotional and behavioral responses to changes in blood tryptophan levels. however. is found in food. tryptophan. This diminished the brain’s ability to make 5-HT. Low 5-HT function would certainly explain the depressed mood and large appetites demonstrated by most women with bulimia nervosa. only those who had bulimia nervosa reported significant increases in dysphoria.Causes of Eating Disorders function may explain binge eating. An amino acid required to make 5-HT.

21.17 Genes that influence serotonin function have been implicated in the etiology of anorexia nervosa. Biological studies indicate that genes contribute to the development of eating disorders. Finally.25 If genes fully explained the occurrence of eating disorders. Among monozygotic twins who share 100% of their genes. it is also important to recall that different factors may provide protection against the development of eating disorders. eating disorders are actually quite rare. and no single factor alone can completely explain all eating disorders. considering how common anorexic-looking beauty ideals are in our culture. psychological factors are important but do not fully explain the onset of eating disorders. There are many perfectionistic girls who struggle with selfdoubt and feel overweight who will never develop an eating disorder. Although eating disorders have clearly increased as a consequence of media exposure to the thin ideal of beauty.17 Studies of serotonin suggest decreased function in patients with bulimia nervosa20. For example. Similarly. then concordance rates would be 100% in identical twins. In addition to appreciating the role of different factors in increasing risk for eating disorders. concordance rates for eating disorders have ranged from 23%24 to 83%. It is quite likely that the vast major- . social pressures to be thin cannot explain eating disorders.23 • • • • • • • SUMMARY Eating disorders are caused by multiple factors. genes clearly contribute to the risk for developing an eating disorder. but genes do not create a fate.22 and possibly increased function in patients with anorexia nervosa.72 Eating Disorders binge eating in people whose brains react differently to decreased tryptophan.

Causes of Eating Disorders ity of people could never develop anorexia nervosa simply because their bodies would not allow them to sustain a dangerously low weight. so that occasional binge episodes do not become a pattern. Similarly. Thus. 73 . but one never goes on a diet because she grows up in a household or community that bases self-worth on qualities other than weight. one must consider all the different forces that both placed him or her at risk or protected him or her at various times during life. to understand the emergence of an eating disorder in a particular individual. Two people may have the same genetic risk for developing an eating disorder. there may be people for whom vomiting does not come easily. This same phenomenon may explain why weight loss diets are so difficult to maintain.

and binge eating disorder. Medications change the way brain cells communicate with each other. mood stabilizers. the primary component of marijuana has been tested in the treatment of anorexia nervosa in the hopes that the commonly known side effect—increased hunger. Of this impressive array of medications. In particular. For example. antidepressants have become the clear medication of choice in the treatment of bulimia nervosa. Several different medications have been studied for the treatment of anorexia nervosa. This did not prove to be successful. and social factors are all important in understanding the causes of eating disorders. opioid antagonists. bulimia nervosa. This chapter describes different treatments that have proven successful in helping girls and women overcome their eating disorders. these factors play important roles in the successful treatment of eating disorders. Other tested medications include antidepressants. antipsychotics. and stimulants. and some data support their efficacy in the treatment of binge eating disorder. psychological.6 Treatment Just as biological. fluoxetine (commonly known by the 74 . BIOLOGICAL TREATMENTS Medication is the main form of biological treatment used for eating disorders. or “the munchies”—would induce patients to eat.

This is called a doubleblind study because both the patient and the physician are blind to what the patient is receiving. This kind of study design is needed because a great deal of research has shown that people will spontaneously get better when they simply believe they have been given medication for a problem. however. researchers randomly assign research participants to either receive the medication or to receive a placebo. 75 . The response to the two treatment conditions can then be compared. A placebo is a substance that is known to have no real effect on the problem. At the end of data collection. For this reason. too). This phenomenon has been demonstrated in patients being treated for everything from depression to cancer (and for eating disorders. preventing the physician from being able to tell who is receiving medication versus placebo eliminates any possibility of bias in reporting the patients’ responses. known as its efficacy. the placebo is shaped to look exactly like the medication so that neither the research participants nor the physicians prescribing the medication for the study know which participants are receiving medication and which are receiving the placebo. it may be difficult for a physician who knows that one patient is receiving active medication not to perceive the person as getting better compared to another who is receiving placebo. coordinating researchers. who do not interact with patients and do not disclose information to physicians.Treatment Methods for Evaluating Whether Medications Work To test how well a medication works to treat a problem. In addition. reveal which patients were receiving medication and which were receiving the placebo.

One way of decreasing the activity of a neurotransmitter is to use medications that block the receptor so that they cannot receive the message. Fluoxetine can also cause sleep . norepinephrine. one side effect of fluoxetine is gastrointestinal (GI) discomfort. The second brain cell receives the message when the neurotransmitter binds to a receptor.76 Eating Disorders trade name Prozac®) is the only drug that currently has Food and Drug Administration (FDA) approval for treating bulimia nervosa. A particular benefit of fluoxetine is its low risk of side effects. the first brain cell must release the small chemical messenger. these medications increase the amount of neurotransmitter that can be received by the second brain cell. a class of neurotransmitters that includes serotonin. called a neurotransmitter. This means that it specifically increases the activity of serotonin without significantly impacting the activity of other monoamines. and dopamine. In order for one brain cell to get a message from another brain cell. Brain cells “talk” to each other by passing small chemical messengers back and forth. much like passing notes in class. Most antidepressants work by increasing the activity of monoamines. most notably the intestines. fluoxetine is a selective serotonin reuptake inhibitor (SSRI). it is also found in other parts of the body. As a consequence. However. One way of increasing the activity of a neurotransmitter is to prevent a process known as reuptake—a process in which the first cell that released the neurotransmitter also reabsorbs some of the neurotransmitter. Serotonin is not just found in the brain. However. Neurotransmitters fit into receptors like a key fits into a lock (Figure 6. Reuptake inhibitors prevent this from happening. this problem usually goes away within four weeks of beginning treatment. By preventing the first cell from reabsorbing the neurotransmitter it just released.1). For the brain to work. brain cells need to communicate with each other.

difficulties—particularly at the doses that are required for treatment of bulimia nervosa. another medication will sometimes be prescribed along with fluoxetine to improve sleep.Treatment Presynaptic nerve ending Neurotransmitter-containing vesicle Neurotransmitter Synapse Neurotransmitter receptor on postsynaptic neuron Postsynaptic neuron Figure 6. In contrast to fluoxetine for treating bulimia nervosa. Fluoxetine can cause dry mouth and has been associated with a decreased sex drive.1 Brain cells communicate by sending small chemical messengers called neurotransmitters to bind to receptors. Neurotransmitters fit into receptors like a key fits into a lock. is not recommended for the treatment of eating disorders because of evidence that it may increase the likelihood of seizures among 77 . another antidepressant. bupropion (trade name Wellbutrin®). For this reason.

only one treatment has received strong support as being superior to alternative treatments—cognitive behavioral therapy.” This belief can be challenged in several ways that are based on the patient’s own observations. There is some limited evidence that selective serotonin reuptake inhibitors may decrease risk of relapse among women with anorexia nervosa who have achieved weight recovery. the patient can be invited to question the value of love from an individual who places so much importance on physical appearance. Third.78 Eating Disorders patients. PSYCHOLOGICAL TREATMENTS Psychological therapies tend to be evaluated by two criteria. First. It increases the amount of norepinephrine available to the receptors of a neuron by decreasing the amount that is reabsorbed by the axon of the communicating neuron. First. Bupropion is a norepinephrine reuptake inhibitor. a cognitive-behavioral therapist may get a statement from a patient concerning the importance of being thin. Cognitive-behavioral therapy views eating disorder symptoms as a combination of irrational thoughts that need to be elicited. For example. the patient can be asked whether there is anyone he or . does a person receiving a particular therapy do better than someone who received a different therapy? Several types of psychological treatment have been tested for eating disorders. almost any psychological treatment is better than no treatment. and behaviors that are reinforced (through positive and negative reinforcement) by immediate consequences. such as: “People will only love me if I’m thin. the patient can be asked to notice couples in public settings and observe that many overweight people appear to be in happy relationships. and replaced. does a person receiving a particular therapy do better than someone who received no therapy? Second. That is. Second. challenged. However. and almost all satisfy the first criterion.

developed by Christopher Fairburn of Oxford University in England. identifying as many alternative responses to the problem as possible 4. acting on the selected response. examining the consequences associated with each alternative response 5. choosing the best response (or combination of responses) available. dieting. prescription of a regular pattern of eating at least 3 meals and 2 to 3 snacks per day (going no more than 2 to 3 hours between eating). In the end. identifying the problem as soon as possible 2. binge eating and inappropriate compensatory behavior with a diary. 2. a grandparent or close friend). 79 . specifying the problem as accurately as possible 3.” One widely used cognitive-behavioral therapy.Treatment she loves who is not thin (for example. based upon anticipated consequences 6. stimulus control (identifying triggers for binge-eating episodes and avoiding these). self-monitoring of food intake. education about weight regulation. The steps of problem-solving include: 1. the patient may come to adopt a belief that corresponds more closely to reality: “People who truly care about me as a person will love me no matter what I weigh. is divided into three stages. These techniques include: 1. The second stage reduces dieting and body image disturbance through a combination of behavioral and cognitive techniques and trains the patient to engage in problem-solving. and 4. 3.26 The first stage establishes control over eating with behavioral techniques. and the risks of purging.

For example.27 This family systems . it may be more appropriate for patients with anorexia nervosa than patients with bulimia nervosa because of the age differences between diagnostic groups. SOCIAL TREATMENTS So far. cognitive-behavioral therapy is considered the treatment of choice for bulimia nervosa. are featured prominently in each stage of therapy. At this time. Unfortunately. Family therapy is more often used when the patients are children or adolescents who live at home. patients are encouraged to recognize and challenge dichotomous thinking in order to differentiate a lapse from relapse. One treatment has emerged that appears to be helpful in treating adolescent patients with anorexia nervosa—family therapy. Traditional family therapy involves evaluating the entire family as the patient. homework assignments. Therefore. it has not proven helpful in treating underweight patients to achieve weight gain. Numerous studies support the efficacy of cognitive-behavioral therapy in the treatment of bulimia nervosa and binge eating disorder. Although selective serotonin reuptake inhibitors may be helpful in preventing relapse among patients who have regained weight. since most of patients’ lives go on outside of the therapy setting. Eliminating all-ornothing thinking allows patients to have slips without having a full return of the eating disorder. Cognitive behavioral therapy emphasizes work that patients complete outside of sessions. For these reasons. cognitive-behavioral therapy has not demonstrated superior efficacy in the treatment of anorexia nervosa. such as maintaining a diary and writing out stages of problem-solving.80 Eating Disorders The third stage works towards maintenance of progress and reduction of risk for future relapse. this chapter has discussed the failure to find treatments that are successful for patients who are actively suffering from anorexia nervosa.

Enmeshment represents poorly differentiated boundaries. as children become adults) and in response to external events (e. Girls in enmeshed families were stifled in their attempts to achieve independence and establish relationships outside the family. family conflict had no means for outlet because distress was suppressed behind a façade of closeness. and concern about bodily functions. spousal. That is. The lack of boundaries among family members triggered conflict as girls approached adolescence. For example. Clarity of boundaries may differ across family members and may change within a family over time. Salvador Minuchin and his colleagues at the New York University Medical School proposed that families in which anorexia nervosa arose were marked by the following characteristics: enmeshment within the family. Boundaries between subsystems can range from enmeshed (too weak) to disengaged (too strong). According to the family systems model. all families are made up of subsystems (e.g. the family moves). Because there was no viable option for expressing interpersonal conflict. children are invited into transactions that would typically remain between husband and wife (spousal subsystem).. According to this model.e. eating. parental.Treatment approach viewed the child with anorexia nervosa as being the identified patient—the person whose behaviors revealed prob- lems in the social interactions of the family.. conflict avoidance. family systems are required to change in response to the normal processes of development (i. Within Minuchin and 81 . overprotection of children resulting in rigid boundaries separating family members from extrafamilial relationships. Indeed. and diets. conflicts were expressed as physical conditions.g. conflicts were somaticized. including physical symptoms. Disengagement represents boundaries that create isolation among family members.. and sibling) in which different roles and responsibilities occur.

the conflict could be revealed in any number of physical maladies within any member of the family. Negotiations for a New Pattern of Relationships: Once patients show willingness to participate in refeeding and achieve weight gain. and issues are covered only to the extent that they are relevant to the patients’ symptoms.82 Eating Disorders colleagues’ framework. A newer approach to family-based therapy invites family members to be members of the treatment team rather than the patient. weight gain with the least amount of conflict is allowed. 3. the focus shifts to encouraging a healthy . and increase acceptance of children’s growing autonomy.28 the Maudsley model of family therapy has received increased attention and empirical support in the treatment of adolescents with anorexia nervosa. Although symptoms remain central to this phase of treatment. reinforce the boundaries of subsystems. 2. Refeeding the Client: Therapists support and reinforce parents’ efforts to refeed their child and encourage parents to form a united front. Traditional family therapy sought to help family members recognize family conflicts. Termination: After the patient has achieved a healthy weight. only issues that impact the parents’ ability to ensure patients’ weight gain are covered. Meanwhile. Following a study indicating the superiority of a family treatment for younger eating disorder patients. As with cognitive-behavioral therapy. other family issues are introduced to therapy. Of note. siblings are encouraged to be supportive of the patient. and this reinforces appropriate boundaries between parental and sibling subsystems. there are three phases to family therapy as developed by the Maudsley group: 1. Families are encouraged to devise their own plans for refeeding.

and preparation for children’s departure from home are often covered in this phase. despite many impressive gains in treatment over the past 20 years. most people who suffer from eating disorders never seek treatment. a lot of work still needs to be done. effective treatments have limited applications. Two studies have supported the efficacy of family therapy over alternative therapies in patients with anorexia nervosa. even though effective treatments produce responses that are better than alternative treatments.Treatment relationship between patients and parents. 83 . the patients’ illness forms the basis of family interactions. Third. most individuals with eating disorders do nothing. So. As a result. or for any age group suffering from EDNOS. many people who receive the most effective treatments do not respond to treatment. At this time. Reflecting the age of patients. appropriate family boundaries. even though there are treatments that improve outcome compared to doing nothing. there are still several important observations that need to be made. First. other than binge eating disorder. However. themes of increased autonomy. until this point. Second.29 and sustained benefits of the intervention were supported in a fiveyear follow-up study30 of the original study. This is particularly important because. • • • • • • • SUMMARY This chapter has focused on treatments with the best evidence of effectiveness. for adults who suffer from anorexia nervosa. we have no known effective treatment for adolescents who suffer from bulimia nervosa.

DESCRIPTION OF FULL ARRAY OF EATING DISORDERS Most people who suffer from eating disorders do not meet diagnostic criteria for anorexia nervosa. There are two possible approaches to characterizing eating disorders. Higher frequencies create higher notes. bulimia nervosa. The difference between one musical note and another is quantitative—the frequency of vibration causes the specific pitch of a note. places all disorders on a spectrum and views associations among different types of eating disorders as being like different musical notes on a scale. However. As a consequence. you have a way to understand the basic principles of all musical notes.7 Future Directions Although eating disorders have existed for centuries. In the spectrum of eating disorders. one EDNOS can be as different from another EDNOS as anorexia nervosa is different from bulimia nervosa. or binge eating disorder. Their problems fall within the category of eating disorders not otherwise specified (EDNOS). called the dimensional approach. we know very little about the problems that most people with eating disorders have. the field of studying eating disorders is relatively young. the quantitative dimension might be thought of as the severity of different 84 . Once you understand the fundamental principles of one note. One approach. There is a great deal of work yet to be done in addressing these problems.

with the example of weight. and three times a week is more severe than twice a week. As appealing as this approach may seem. the difference between anorexia nervosa—binge/purge subtype and bulimia nervosa may be represented as a quantitative difference in weight that is directly related to a quantitative difference in severity. there are problems with it. The greatest problem is deciding where to draw 85 . Like the dimensional approach.2). For example. First. such that no unique threshold exists between people who binge eat twice a week versus once a week—twice is simply more severe than once. Second. there may be a unique threshold between never engaging in a behavior (e. It simply views disorders as existing in unique classes—like different genes contribute to the risk for developing anorexia nervosa versus bulimia nervosa. The extent that anorexia nervosa exists across cultures and through history but bulimia nervosa appears to be a culture-bound syndrome also supports a categorical approach.g. never purging) and purging. The dimensional approach seeks to identify the dimensions that are relevant for understanding the severity of illness but does not attempt to group people into categories. Frequency of behaviors such as binge eating or purging may also be viewed in quantitative dimensions. with the example of frequency of behaviors.Future Directions symptoms.. such that the relationship between severity and frequency becomes non-linear (Figure 7. People who are emaciated and those who are obese face greater medical risks than individuals who are normal weight (Figure 7. the categorical approach has problems.1). The categorical approach is an alternative to the dimensional approach. This approach is similar to the model used in medicine to diagnose diseases. the association between weight and severity is not linear. It views eating disorders as falling into distinct types.

In the current edition’s diagnostic criteria. in the third edition of the APA’s diagnostic system. first published in 1994. such as weight or binge frequency.Eating Disorders boundaries between one type of eating disorder and another— particularly with regard to features that lie on a dimension. For example.1 Low 86 Emaciation Average Weight Obesity . an individual needs to maintain weight at less than 85% of what Medical Risk High Table 7. published in 1980. diagnostic criteria for eating disorders have changed over time and differ between the classification systems created by the American Psychiatric Association (APA) and the World Health Organization (WHO). Reflecting the uncertainty of where true boundaries exist. an individual had to lose 25% of his or her previous weight to be diagnosed with anorexia nervosa.

2 None Low Severity High RELATIONSHIP BETWEEN SEVERITY AND PURGING FREQUENTLY Never Once 5 Lifetime Purging Frequency 10 87 . the disorders can be diagnosed simultaneously in the WHO’s diagnostic system.Future Directions would be expected for height to be diagnosed with anorexia nervosa. However. and could be diagnosed simultaneously in the 1987 version of the APA’s diagnostic criteria. Table 7. Thus. even for well-described eating disorders. anorexia nervosa and bulimia nervosa cannot be diagnosed simultaneously in the current APA diagnostic system because a diagnosis of anorexia nervosa trumps a diagnosis of bulimia nervosa. the point at which one disorder is diagnosed versus another remains unclear. As described in Chapter 1.

Should Beth. Do specific EDNOS cluster within families—that is. relapse. or are they just as likely to have an EDNOS that is similar to Ben’s? 3. and Pearl all be diagnosed with one type of eating disorder? Should they be diagnosed with four different types of eating disorders? To answer these questions. Would Pearl be just as likely to respond to these treatments. Do different EDNOS respond to different kinds of treatments? We know that Beth and Ben are likely to get better with medication. Do people with EDNOS demonstrate all possible variations in symptom combinations with similar frequency? Or do certain sets of symptoms cluster together more often than would be expected by chance? 2. or does she need something different to help her overcome her eating disorder? 4.88 Eating Disorders Consider now the uncertainty surrounding all of the different possible variations one could show in disordered eating. . Ben. are Pearl’s biological relatives more likely to have an EDNOS that is similar to Pearl’s. Do different EDNOS have different outcomes? Is the likelihood of recovery. Do the biological bases of different EDNOS differ? Does reduced serotonin function contribute to all of the different EDNOS or are some characterized by increased serotonin function or dysfunction in different systems? These types of questions require further research to accurately describe the full array of eating disorders. we need studies that examine the following questions: 1. or death different for Ben than for Pearl? 5. Nina.

To receive funding. surprisingly little is known about how to successfully treat this disorder. what would you fund? Currently. Thus. Second. An independent group of researchers reviews all grant proposals that are submitted for funding. Across treatment studies. most research that is conducted on eating disorders in the United States is funded by the National Institutes of Health (NIH). few have demonstrated any What Research Would You Fund? If you had $5 million to fund any type of research program for eating disorders. the disorder is relatively rare. Thus. First. citizens. The NIH receives funding from the federal government based on taxes paid by U. researchers write grant proposals in which they describe what kind of study they want to do and why they want to do the study. These reviewers evaluate what proposals pose the most important goals and what proposals are most likely to successfully meet their goals.S. any controlled study is always comparing two active treatments in an attempt to determine if one is superior to another. You can influence the types of research that are funded by the NIH by contacting your congressional representatives and expressing your opinions on what types of health problems need more funding. 89 . Features unique to anorexia nervosa make it difficult to examine in controlled treatment studies. the severity of the disorder makes no-treatment control trials unethical. only centers specializing in the treatment of eating disorders see large enough numbers of patients to conduct controlled treatment trials.Future Directions TREATMENT OF ANOREXIA NERVOSA Although anorexia nervosa has arguably existed longer than any other eating disorder and is associated with the greatest risk of death.

PREVENTION Even if all eating disorders could be appropriately characterized and effective treatments could be developed for all eating disorders. For this reason. People have been working on prevention for some time and with some limited success. support for this treatment is limited both in terms of the number of studies supporting the efficacy of family-based therapy and in terms of the population with whom it works. family-based therapy may only be helpful for adolescent patients. To address this gap in the field. Limited understanding of risk factors for eating disorders . money. and—most importantly— suffering. Most often. One challenge in preventing eating disorders is that we do not completely understand the risk factors that explain why one person develops an eating disorder and another person does not. but they will not report reduced dieting. the number of individuals suffering from eating disorders far exceeds the availability of treatment for eating disorders. However. The one set of studies suggesting any superior treatment effect has supported familybased treatments discussed in Chapter 6. For example. the National Institutes of Health (NIH) announced a program in 2003 to fund a multisite treatment study for anorexia nervosa. Specifically. prevention participants may report less body dissatisfaction. effective prevention would save time. Simply put.90 Eating Disorders significant differences in remission rates. several experts within the field have directed their attention toward the goal of prevention. The purpose of the initiative is to encourage collaborative research among different groups specializing in the treatment of anorexia nervosa to recruit large enough numbers of patients to detect what may be modest but important differences in treatment efficacy. prevention efforts have produced improvements in knowledge and attitudes but not behaviors.

However. within the Health Promotion Paradigm.2 hours of television per day in one study. a protective factor promotes wellness when present and does nothing when absent. Duration of many programs has been limited to three or five sessions. and overvaluation of thinness/denigration of fatness or “weightism”).33 it is unclear how one video could demonstrate any lasting influence on attitudes. In addition to focusing on protective factors. For example. sexism.Future Directions reduces the success of prevention programs that attempt to reduce risk factors.31 This prevention model emphasizes protective factors rather than focusing on risk factors. The Health Promotion Paradigm is one approach to prevention that does not rely on altering specific risk factors. The goal of instilling the value of diversity among school children is not specifically related to the goal of preventing eating disorders. This intervention would seek to reduce prejudice in all of its forms (racism. sex.32 Given that girls reported watching 3. schools would be encouraged to promote valuing individual differences with regard to race. A third challenge in prevention is the limited scope of 91 . A second challenge in prevention has been that improvements immediately after intervention tend to disappear over the course of follow-up. In fact. promoting health in the general population through promoting tolerance may reduce illness in individuals. and weight. The solution to this challenge requires increasing resources for implementing prevention programs. Whereas a risk factor promotes illness when present and does nothing when absent. two prevention studies utilized a single 22-minute videotape as the prevention. Modest improvements of limited duration may be explained by the use of modest interventions of limited duration. the Health Promotion Paradigm targets change in the actions of the community in addition to changes in the behavior of a given individual within that community.

all of which influence the development of eating disorders. Perhaps another reason for limited success of prevention programs is the failure to critically evaluate these assumptions. Develop approaches to assess and minimize harmful effects of interventions. clinicians. body image. the following recommendations were provided from a roundtable discussion of experts convened by the National Institute of Mental Health (NIMH): 1. The first assumption is that social factors have the greatest influence on the development of eating disorders. Develop guidelines for assessing the scientific merit of eating disorders prevention trials. and societal norms and values. 4. and other researchers in the field. and outcomes to better assess progress in epidemiology and prevention trials. In contrast. 2. Foster cross-discipline interactions among animal experimentalists. personality traits. treatment spans the full range of social. Encourage research on neural mechanisms of eating disorders at the animal level. So far. syndromes. Encourage the integration of basic social science research in prevention approaches.92 Eating Disorders programs. family and social groups. To improve future prevention programs. risk factors. and biological factors. and dieting). 5. 3. prevention programs have focused almost exclusively on the psychosocial factors described in Chapter 5 (media images. The second assumption is that social factors are the easiest to change. psychological. Develop common definitions of symptoms. The primary emphasis on social factors within prevention programs has two implicit assumptions. . 6. Encourage research in biology.

Future Directions 7. 93 . Increase awareness that eating disorders are a public health problem and that prevention efforts are warranted.34 These recommendations reflect an expansion of prevention paradigms to examine the full range of etiological risk factors in eating disorders. the next big break in the field is likely to come from someone who approaches the problem from a fresh perspective—someone like you. These recommendations also reflect some of the impediments to developing efficacious prevention programs. Adopt an approach that considers public health impact of these disorders. from biological to sociocultural factors. As such. • • • • • • • SUMMARY This chapter has focused on future directions for the field of eating disorders by providing a few examples of topics that require further work. there will always be more work to do. 8. there is a great deal more work that needs to be done than has been described in this chapter. Until eating disorders are fully eradicated from human experience. Such ill-informed beliefs reduce support for prevention resulting in the limited success of this important endeavor. These range from deficits in understanding the exact causes of eating disorders to societal stigmatization of eating disorders as problems that people choose to have. Identifying the right questions is as much a part of reaching that goal as getting answers to the questions already posed. However.

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accompanied by a feeling of a loss of control over eating. Antidepressant—Medication that reduces feelings of distress. Boundary—Demarcation between subgroups in a family and between family and non-family members Bowel function—Workings of the intestines. Binge eating disorder (BED)—An eating disorder characterized by recurrent binge eating episodes that causes significant distress to the person. some bacteria cause disease. Categorical approach—View of disorders as being distinct from one another. Amino acid—Basic building block for proteins. an amount of food that is substantially larger than most people would eat under similar circumstances. Cerebrospinal fluid—Liquid in ventricles in which by-products of brain activity are flushed out of the brain. Anorexia nervosa—An eating disorder characterized by self-starvation in which a person refuses to maintain a normal weight and fears weight gain. within a limited period of time. Candidate gene study—Investigation that examines whether a specific gene is associated with the presence of illness. 97 . Chemotherapy—The use of chemical agents to treat or control a disease. Antipsychotic—Medication that reduces problems characterized by distortions of reality.GLOSSARY Allele—Alternative forms that a gene can take. Cognitive abilities—Mental abilities such as thinking. Bulimia nervosa—An eating disorder characterized by recurrent binge eating episodes coupled with extreme measures to counteract the effects of eating on weight (such as self-induced vomiting). Cognitive disinhibition—Loss of control over behavior that is triggered by thoughts. Bacteria—Single-celled organisms too small to be seen without a microscope. Attention—Cognitive ability to maintain mental focus. Binge eating—Eating. Axon—Part of a brain cell that sends messages to other cells. most commonly cancer.

Confidentiality—The protection of privacy by not sharing information. Constraint—Control over behavior.Compulsive—Refers to a drive to reduce anxiety or threat. Efficacy—Ability of a treatment to produce superior outcomes compared to a control condition. Dysphoria—The state of feeling unhappy or unwell. Diagnostic criteria—The core features of an illness that make up its definition. Dichotomous thinking—Black-and-white thinking in which things are evaluated as either all good or all bad. Dizygotic twins (fraternal twins)—Twins formed by the fertilization of two separate eggs by two separate sperm. like regular siblings born in multiple births. Deoxyribonucleic acid (DNA)—The substance that serves as the building blocks for genes. Diagnosis—Categorization of physical or mental illness by defining core features of the illness and providing a name for the illness. Eating disorder not otherwise specified (EDNOS)—An eating disorder that does not meet diagnostic criteria for either anorexia nervosa or bulimia nervosa. Disengagement—When boundaries are too rigid within families. Dopamine—Neurotransmitter that influences the experience of reward. 98 . Diuretic—An agent that produces loss of water by excess urination. Ego-dystonic—Inconsistent with a person’s sense of self. Culture-bound syndromes—Disorders that occur only in certain cultures and not in others. Constipation—Reduced ability to defecate. Dimensional approach—View of disorders as existing on a continuum. 50% of their genes. Double-blind study—Study in which neither the patient nor the doctor knows if the patient is receiving active treatment. Disability—Loss of function in an important area of life. Decision-making—The cognitive ability to make a choice. Ego-syntonic—Consistent with a person’s sense of self. dizygotic twins share. on average.

Lanugo—Fine. Hyperglycemia—Excessive concentrations of sugar in the blood. 5-hydroxytryptamine (5-HT)—Serotonin.Electrolytes—Substances in the body that carry an electrical charge. Lanugo can occur in anorexia nervosa. Impulsive—Referring to drives to increase reward or gratification. Fasting—Extended periods of avoiding food intake. Gray matter—Part of the brain that contains brain cells. potassium. Emaciated—Extremely underweight. Epidemiology—The study of rates of a disorder in a population. a neurotransmitter that influences satiety. Esophagus—The muscular tube between the throat and the stomach. Enmeshment—When boundaries are too weak within families. Excessive exercise—Physical activity that goes beyond what is required for physical fitness or performance. Genotype—Basic code from which the body is built. 99 . Homozygous genotype—Two of the same alleles comprising a gene. Gluttony—Excessive food intake. Heterozygous genotype—Two different alleles comprising a gene. and sodium. Insulin-dependent diabetes mellitus—Chronic disease caused by the body’s inability to properly produce or use insulin. Medial hypothalamus refers to inner portions of hypothalamus. Identified patient—Family member identified as having an illness within a family in a family systems approach. Insomnia—Inability to sleep. such as calcium. not just the patient. mood. Hypothalamus—Brain structure that influences weight and appetite regulation. downy hair that typically is present on fetuses before birth to regulate body temperature. Heterogeneous—Differing. Etiology—Cause. Gene—Part of the code for building the body. Hypokalemia—Insufficient concentrations of potassium in the body. Family systems approach—Therapy in which the entire family is seen as having an illness. and impulse control.

Opioid antagonist—Medication that reduces the function of pain-relieving neurotransmitters. Neurotransmitter—Chemical released from brain cells that allows brain cells to communicate with other cells. Monozygotic twins (identical twins)—Twins that share 100% of their genes. Memory—Cognitive ability to store information in the mind. Menstrual period—Monthly shedding of uterine lining (appears to be bleeding) in post-pubertal females. Non-volitional—Not of one’s own choosing. Obese—Extremely overweight. Laxative—An agent that produces loss of matter by excess defecation. Monoamine—Class of neurotransmitters. Placebo—An inactive substance made to look like active medication and used as a control condition. Protective factors—Factors that reduce probability of developing illness.Lapse—A return of symptoms that represents a slip but not a return of the disorder. 100 . Perfectionistic—Having a tendency to strive toward flawlessness. Norepinephrine—Neurotransmitter that influences activity level and appetite. Parotid glands—Glands that produce saliva. Mood stabilizer—Medication that reduces extreme emotional fluctuations. Positive reinforcement—Consequence of behavior that increases frequency of behavior by providing something rewarding. Phenotype—The observable expression of genes. Molecular genetic study—Investigation that examines specific genes in relation to illness. Problem-solving—Cognitive ability to resolve difficulties or puzzles. Planning—Cognitive ability to organize a series of future actions. Negative reinforcement—Consequence of behavior that increases frequency of behavior by removing something unpleasant. Overeating—Consuming an excessive amount of food but not feeling a loss of control of eating. Neuron—Brain cell.

laxative use. and impulse control. Subsystem—Subgroup within a family. Withdrawal—Effects that result from removing substance to which the body has developed tolerance. and reduces appetite. mood. White matter—Part of the brain that contains axons. Shared environment—External influences that are common to twins reared together (regardless of whether they are identical or fraternal twins). Remission—Reduction in the severity of symptoms. Risk factors—Factors that increase probability of developing illness. Reuptake—When the brain cell that is releasing a neurotransmitter reabsorbs the neurotransmitter before it binds to a second brain cell’s receptors. Twin concordance—Similarity between twins.Purge—Extreme method of weight control/compensation for binge episodes that involves forceful evacuation of matter from the body. Satiety—The feeling of fullness. Somaticize—Express emotional distress as bodily complaints. and diuretic use. Symptoms—Features of an illness. Recall—Cognitive ability to retrieve information stored in memory. Serotonin (5-HT)—Neurotransmitter that influences satiety. Relapse—A return of symptoms that represents the return of the disorder. euphoria. Stimulant—Medication that increases sense of energy. Ventricles—Fluid-filled core of the brain. Selective abstraction—Thinking that substitutes one part of something for its whole. Tryptophan—Amino acid that is needed to create serotonin. 101 . Selective serotonin reuptake inhibitors (SSRIs)—Medications that prevent a brain cell that released serotonin from reabsorbing serotonin before it can bind to the receptor of another cell. including self-induced vomiting.

Hove. 5th ed. R. Norton and Company. New York: Harper Collins. Eating Disorders.. Apostolides. East Sussex. Sacker. C. Am I Thin Enough Yet?: The Cult of Thinness and the Commercialization of Identity. U. Body Blues: Weight and Depression. 1998. Exercise Addiction: When Fitness Becomes an Obsession. Eating Disorders: A Handbook for Teens. J. Inc.. Getting Better Bite by Bite: A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders. Eating Disorders: The Facts. Kalodner. T. Inner Hunger: A Young Woman’s Struggle Through Anorexia and Bulimia. P. NJ: Prentice Hall. and M. 1996. 1998. Costin. 1993. London: Oxford University Press. 2005.. S. C. L. 1997. 102 . S. J. Hesse-Biber. CA: New Harbinger Publications. A. Upper Saddle River. UK: Psychology Press. Kolodny. Too Fat or Too Thin?: A Reference Guide to Eating Disorders. Wasted: A Memoir of Anorexia and Bulimia. 1987. The Beginner’s Guide to Eating Disorders Recovery. Oakland. Los Angeles: Lowell House. and J. Dying to Be Thin: Understanding and Defeating Anorexia Nervosa and Bulimia—A Practical.FURTHER READING Abraham. Sandbek. 2004. L. Jefferson. New York: Rosen Publishing Group. New York: Warner Books. Weeldreyer. Families and Teachers. K. M. 1997. New York: Oxford University Press. New York: Simon & Schuster. CA: Gurze Books. 2003. Heller. Carlsbad. M. 1998. Lifesaving Guide. Bode.. Keel. I. T. The Eating Disorder Sourcebook. 1998. 2003. Llewellyn-Jones. Zimmer. Kaminker. Treasure. 1993. Food Fight: A Guide to Eating for Preteens and Their Parents. The Deadly Diet: Recovering From Anorexia and Bulimia. 2001. J. New York: Rosen Publishing Group. W. and D. N. Schmidt. CT: Greenwood Press. New York: W. Westport. Hornbacher. NC: McFarland and Co. M..

htm 103 .org Ohio State University FactSheet.ama-assn.htm International Eating Disorder Referral Organization http://www.com/binge.com/binge/binge_overview.htm The Nation’s Voice on Mental Illness: Bulimia Nervosa http://www.4woman.niddk.com Eating Disorders Information Network http://www.eatingdisorders.edreferral.gov/publicat/eatingdisorders. Eating Disorders Awareness: Bulimia Nervosa http://ohioline.au American Psychiatric Association http://healthyminds.org Archives of Family Medicine http://archfami.healthieryou.org/index.nami.gov/faq/Easyread/bulnervosa-etr.gov/publications/binge.com/ US Department of Health and Human Services: Bulimia http://www.nationaleatingdisorders.overeatersanonymous.org/ National Eating Disorders Association http://www.org/cgi/content/full/9/1/88 Science Central http://www.nih.html Weight-control Information Network http://win.gov/faq/easyread/anorexia-etr.edin-ga.org.cfm Eating Disorders Foundation of Victoria http://www.htm A Weigh Out http://www.html Something Fishy: Website on Eating Disorders http://www.healthywithin.aweighout.nih.html Overeaters Anonymous http://www.osu.nimh.WEBSITES National Institute of Mental Health http://www.php Healthier You: Binge Eating Disorder http://www.4woman.org/ Healthy Within http://www.com/causes.asp US Department of Health and Human Services: Anorexia http://www.somethingfishy.edu/ed-fact/1003.org/whatarethey/ednos.sciencentral.

Eating disorders in Figure Skaters and Non-skaters
http://www.angelfire.com/il2/figskating/issues/ed.html

Anorexia Nervosa and Related Eating Disorders, Inc.
http://www.anred.com/welcome.html

Helpguide: Eating Disorders: Types, Risk Factors and Treatments
http://www.helpguide.org/mental/eating_disorder_treatment.htm#treatments

National Eating Disorder Screening Program
http://www.mentalhealthscreening.org/events/nedsp/index.aspx

The Center for Young Women’s Health Eating Disorders: A General Guide for Teens,
Children’s Hospital Boston
http://www.youngwomenshealth.org/eating_disorders.html

Eating Disorders Association
http://www.uq.net.au/eda/documents/eatingdisordershealthpromotion.html

104

INDEX

5-hydroxytryptamine (5-HT). See
Serotonin
American Psychiatric Association (APA),
86–87
Amino acid, 71
Anorexia nervosa, 5, 7, 48, 72
case studies, 1, 3, 11–14
behavioral effects, 20–21,25
cognitive effects, 17–20, 42
defined, 3
diagnosis, 8, 84, 87
effects of, 14–22, 54
emotional effects, 17, 19, 64
history of, 6
interpersonal effects, 21–22, 26
mortality, 6, 16–17, 26, 28–30, 89
physical effects, 15–16, 24
recognizing, 22–25, 55
remission, 90
research studies on, 18–19, 65, 89–90
response to, 26–28, 56
at risk for, 6, 9, 29, 59, 65, 69, 71–72, 85
statistics, 6, 23, 61
symptoms and signs, 3–6, 11–15, 17–26,
30, 35, 58, 64–65, 70, 85
Antidepressants
action, 76
treatment of binge eating disorder, 74
treatment of bulimia nervosa, 74, 76–78
Antipsychotics, 74
APA. See American Psychiatric
Association
Bell, Rudolph, 5
Binge eating disorder
case studies, 51–52
defined, 48–49
diagnosis, 84
history of, 8
research on, 56, 61–65, 71

at risk, 8–9, 65, 70, 72
statistics, 8
symptoms and signs, 1, 8, 49–55, 61, 63,
71–72, 85
treatments, 74, 80, 83
Biological causes of eating disorders,
66–72, 74, 92–93
genes and eating disorders, 66–69, 72
serotonin function and eating disorders, 69–72
Biological treatments of eating disorders,
74–78
medications
antidepressants, 74
antipsychotics, 74
marijuana, 74
mood stabilizers, 74
opioid antagonists, 74
stimulants, 74
Bruch, Hilde, 65
Bupropion. See Wellbutrin®
Bulimia nervosa, 48
case study, 31–34
behavioral effects, 43–44
cognitive effects, 42–43
diagnosis, 8, 84, 87
effects of, 35–44, 54
emotional effects, 30–31, 33, 38–42, 44
interpersonal effects, 30, 44–45
mortality, 29–31, 36, 38
recognizing, 45, 55
research, 65, 71
response to, 56
at risk, 7–9, 29, 59, 63, 65–66, 69, 72, 85
statistics, 7, 61
symptoms and signs, 1, 7, 29–38, 40–45,
54, 58, 61, 63–66, 71
treatments, 63–64, 74, 76–77, 80, 83
Cognitive behavioral therapy, 82
and treatment of eating disorders, 63,
78–80

105

Cognitive disinhibition, 62–63
Culture-bound syndrome, 85
Dieting, 3, 23, 31, 79, 92
and binge eating, 61–64
and carbohydrate craving, 70–71
failures, 44, 62
industry, 10
physical effects of, 14
Dysphoria, 71
Eating disorders
case studies, 1, 3, 11–14, 31–34, 51–53
causes, 9, 42
characterizing and diagnosing, 84–88
categorical approach, 85–87
dimensional approach, 84–85
future of, 84–93
history of, 4–5
prevention, 90–93
signs and symptoms, 1–8
statistics, 23
study of, 84
treatment, 74–83
Eating disorder not otherwise specified
(EDNOS)
case studies, 51–53
causes of, 58–74
defined, 48–49
diagnosis, 8, 56, 84, 88
effects of, 54–55
future of, 56
recognizing, 55–56
response to, 56–57
symptoms and signs, 8, 48–50, 54–55
EDNOS. See Eating disorder not otherwise specified
Ego-dystonic disorder, 30
Ego-syntonic disorder, 27
Electrolytes, 34

106

Family therapy
boundaries, 81
disengagement, 81
for eating disorders, 80, 90
enmeshment, 81
identified patient, 81
phases, 82–83
subsystems, 81
systems approach, 80–81
Fairburn, Christopher, 79
FDA. See Food and Drug Administration
Fluoxetine. See Prozac
Food and Drug Administration (FDA), 76
Garner, David, 59
Genes
coding, 67–68
and eating disorders, 66–69, 72–73
Gluttony, 8, 40
Gull, Sir William, 6
Health Promotion Paradigm
protective factors, 91
risk factors, 91–93
Heinberg, Leslie, 59
Herman, Peter, 62–63
Heterogeneous disorder, 31
Hyperglycemia, 38
Hypokalemia, 36
Hypothalamus, 69–70
Insulin-dependent diabetes mellitus, 38
Kaye, Walter, 71
Keys, Ancel, 18
Lasegue, Charles, 6
Marijuana, 74
Maudsley model of family therapy, 82–83
Minnesota starvation study, 18–20

81 Monoamines. 80. 58–60. 55 Opioid antagonists. 90 funding. 51–52 Overeating. 74. 8. 80–83 family therapy. 76–77 Psychological causes of eating disorders. Gerald. 56 NIH. Janet. 66–70. 64–66. 69–72. 69–72 Shaw. 80–83. 80 on bulimia nervosa. 56 case study. 92 Social treatments of eating disorders. 74 side effects. 76 and relapse prevention in anorexia nervosa. 10. 61–64 personality and eating disorders. 89–90 National Institute of Mental Health (NIMH). 52–53 symptoms and signs. 88 on genes and eating disorders. 65 Selective serotonin reuptake inhibitor (SSRI). 89–90 on binge eating disorder. 62–63 Prozac® (Fluoxetine). See National Institutes of Health NIMH. 78 positive. 59–60 on medications. 76–77 and the treatment of bulimia nervosa. 65. 54. 76 norepinephrine. See National Institute of Mental Health Non-volitional disorder. 72. 80–83 107 . 61–65. 49–50. 74 National Institutes of Health (NIH). 61–66. 72–73 on media images of the ideal body. Heather. 72. 72 Polivy. 7. 85 Reinforcement negative. 75 on starvation effects. 76 Night eating syndrome. 55 and eating disorders.Minuchin. 76 in eating disorders. 60 Social causes of eating disorders. 54–55 health consequences of. 78 serotonin. 72 Psychological treatments of eating disorders. 92 dieting and binge eating. 85 statistics. See Overeaters Anonymous Obesity. 74. 92–93 media images of the ideal body. 74 Overeaters Anonymous (OA). 80 Serotonin function. 18–20 on twin studies. 78–80 Purging disorder. 68–69. 72 Russell. 20 causes. 63. 59. 79 on family therapy. 3 Perfectionism and increased risk for eating disorders. 78–80 cognitive behavioral therapy. 65. 64–66. 76. 76 Mood stabilizers. 78. 78 Research on anorexia nervosa. 53–57. 89 future of. 71. 80 on cognitive-behavioral therapy. 92–93 Neurotransmitters. 49 OA. 77 dopamine. 71. 58–61. 56. Salvador.

86–87 . Kevin. 4–5 Stice. 60 Stimulants. 24–25. 19 withdrawal. 54 depression. 71 Wellbutrin® (Bupropion). 77–78 WHO. 22. 74 108 Thompson. 59 Tryptophan. Eric. 19 St. 20. J. See World Health Organization World Health Organization (WHO).SSRI. See Selective serotonin reuptake inhibitor Starvation effects. Catherine of Siena.

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Inc..TRADEMARK Atkins is a registered trademark of Atkins Nutritionals. 110 . Wellbutrin is a registered trademark of GlaxoSmithKline. Prozac is a registered trademark of Eli Lilly and Company.

111 .D. in anthropology from Harvard University in 1992 and received a Ph. in clinical psychology from the University of Minnesota in 1998. Keel began conducting research on eating disorders as an undergraduate.AUTHOR Dr. Dr. From there she joined the faculty in the Department of Psychology at Harvard University. Keel received a B. She has published more than 50 journal articles from research she has conducted. she left Harvard to join the faculty in the Department of Psychology at the University of Iowa.A. Pamela K. In 2003. In addition. she authored a book on eating disorders in 2005 for college students. She completed her internship at Duke University Medical Center in 1999.